CHAPTER 11:

Interpretation: Clinical Applications of Content Analysis:

Clinical Applications of Content Analysis:

What Constitutes a Projective Test?

The quantitative inkblot response indices for the Rorschach Holtzman tests and SIS have considerable historical research and clinical merit derived from a foundation of normative data. While assigning numerical summation scores to subjective inner world phenomenon may make such an approach appear “Objective” scientifically, the application of mathematics in this context does not have the same ring of reality as counting physical objects. In recent years, skeptical critics have raised fundamental questions regarding their applicability in 21st century clinical settings.

Historically, the categories “Human”, “Animal” and “Movement” utilize principles of projection, more than those assessing such constructs as “form” and “color”, which are more analogous to measurements made use of in neuropsychological tests. The later indices are based more upon the optics of perception of objects in the outer world, as opposed to the subjective inner world of emotion colored imagery. Consequently for psychometricians to label such tests as strictly “Projective” tends to be somewhat of a misnomer.

Applying Projective Principles in Treatment:

Content analysis is a more of a treatment oriented approach, than diagnostic one. Yet it must be acknowledged that the cost of controlled statistically based therapeutic outcome studies has so far prohibited their completion. However, there are many individual cases with the SIS highly suggestive of clinically significant positive results.

My revised conceptual model proposes that content derived from the phenomenon of “inkblot” projection involves imaginative viewing of visual input, which are sufficiently ambiguous to stimulate the release from memory storage of otherwise unavailable deep seated imagery. What ordinarily is released with content analysis is more akin to fantasy, dreams. PTSD flashbacks etc., and ultimately the suffering individual‘s “inner cry”.

However, it must be acknowledged that content analysis does not readily lend itself to quantification scoring and has been criticized for not being “Objective”. A subject’s projective profile tends to be highly unique and idiosyncratic. Often, the deep seated information surfaces and is projected in a disguised symbolic language, initially interpretable only by a trained professional. Consequently, much of the clinical SIS work has relied on an individual case history reports, as will be illustrated later in this chapter.

In clinical settings, the responses can reflect emotionally charged misperceptions of other “Humans“, the individual’s faulty sense of self as a “Human”, distortions in perception of the individual’s own body, as well of those of others, etc. On a temporal scale, the projected imagery tends to be highly fluid; fluctuating rapidly in the level of projective awareness during the period an inkblot series is viewed.

As previously outlined, the visualized imagery may surface at any point in a spectrum, ranging from either a photographic like representation of past real life events, or their distorted misperceptions. Moreover the images may be projected as symbolic defensive representations. However, in the more severe mental disorders having an organic neurological basis, the mental material that is projected, may primarily reflect underlying neuropathology and symbolism only secondarily.

Prior to the resultant imagery being recognized by the neurophysiologic processes giving rise to awareness and recognition, the inkblot information from the visual input is reshaped by psychological defense mechanisms. These control the competitive balance between “sensitization” and “repression”. The psyche forces attracting an image to the door of conscious awareness and ultimate recognition are opposed by opposing ones activating neural inhibitory processes.

Whether or not the image passes through the door and is then projected onto ambiguous inkblot stimuli depends upon the interplay between such competitions. When threatening affect causes inhibition to override sensitization, then secondarily activated brain circuitry search the same brain regions, as those which give rise to anxiety arousing dreams. Afterwards, if the affect released is potentially too threatening, what is brought to the responder’s projective mind are disguised affect neutralized symbols. While these may have less disturbing affect linkage then the original stressful memories, the unfelt affect may be converted to a variety of secondary physical and mental symptoms.

Of course, this conceptual model needs to be reexamined in association with concurrent neurological studies, such as those involving functional magnetic resonance imaging (FMRI) which measure metabolically active areas of the brain activated during inkblot viewing.

Content Analysis: Rorschach and Holtzman Tests:

Historically, Herman Rorschach’s assessment of content was relatively limited not only due to his early death, but also to the limited understanding of the mental mechanisms underlying mental disorders in his lifetime. He assigned content to one of six categories: Animal content, Human content, Animal detail, Human detail, Inanimate object and Landscape.

Several subsequent workers such as Beck et al. (1961) and Klopfer et al. 1954 expanded upon the number of content categories. Holtzman et al. (1961) included five categories in the HIT as follows: Human, Animal, Anatomy, Sex, and Abstract categories.

The high degree of somatic structure in the SIS taps into an important psychophysiological dimension. Previously, a book written by Schafer (1960), describing the relevance of anatomical content analysis in psychoanalytic treatment was noted. He outlined the importance of “Body Image” concepts as follows: “The blots themselves are equivalent to bodies. Their treatment as stimuli, that is, their use of colors, shadings and forms and their scores reflecting this usage, can be seen to additionally relate awareness of the expression of the subjective experience of bodies”. For a comprehensive overview of the field as it appeared in 1976, the reader is referred to a book written by Aronow and Reznikoff in their book, Rorschach Content Interpretation (1976, Grune and Stratton New York).

Holtzman included five categories in the HIT as follows: Human, Animal, Anatomy, Sex, and Abstract. The one which is least abstract and directly relevant to sexual identity issues is the Sex category. In Holtzman’s handbook, only one psychotherapeutic case report was presented in detail. With Dr. Holtzman’s permission Content analysis was completed by reanalyzing a case history report originally published in1961.

Without being acknowledged, in the book, the case indirectly illustrated the importance of Content analysis with the HIT. The case involved a male university student in psychotherapy, who apparently was experiencing anxiety provoking homosexual fantasies.

When initially tested with the Holtzman Inkblots Form “A” , at A 29 he said “I don’t think that there have been five of these that I haven’t seen a phallic symbol”. Here he directly comments on his sexual perceptual bias.

Now 50 years later, for illustration purposes, a detailed analysis has been given to two of his HIT blots.

Form A

A24: Oh Hell! Hell! I say, because some creature is about to stab another. My word he has an erected penis too. On both sides - strange as it might sound Qc- head arm, pitchfork, penis, stabbing himself - threatening a part of his own body.

It is apparent that blot 24 has brought out threatening imagery with highly charged affect. It projects aggressive feelings initially towards others. After the emergence in projective awareness of to which in 1961 were likely socially unacceptable to himself. This project homosexual conflicted sexually aroused phallic imagery, with an aggression component secondarily directed inwards to himself. The latter could surface as impulses for self mutilation or even suicide. A 21 century symbol trained clinician now would have more understanding and perhaps would be able to further explore these potentially dangerous projective clues. It might be noted that this clinical case presentation was completed when homosexuality was generally considered a mental illness. Thus, his overall chain of inkblot associations brought to the surface, the frequently observed neural connection between the brain’s centers for aggression and those for sexual arousal.

If interested, the reader might refer to a case in my book Body Symbolism (1980) detailing SIS responses in a hospitalized man who practiced same sex behavior. This individual placed burning cigarettes on his skin to arouse erotic feelings. This concomitantly caused physical pain and neurophysiologic excitation, thereby augmenting his libido induced brain’s activity. This for him initially facilitated and then triggered ejaculation. He habitually had learned to self inflict pain by the positive conditioning of sexual pleasure and tension relief.

A11: Oh, no! What I see in these things are unreal (laughing) - they don’t look like these, just resemble them. I see a vagina - a woman with legs spread apart. I laughed because these little caterpillar-like creatures look like they are getting the Hell out of there. Very interesting Qc: suggest that her vagina is in such bad shape, they wouldn’t live there. That’s why I laughed.

This flow of projective somatic images symbolically reflected his own mental picture of a woman’s genitalia. The inkblot stimulated the release of this material that otherwise would be hard to bring out in standard clinical interviews. It was linked with anxiety, which he showed immediately as (Oh no!) and then spontaneously laughed as a further tension lowering mental mechanism. The “little caterpillar-like creatures” symbolized his phallic impressions within his sexually conflicted immature body gestalt. Also projected was symbolism reflecting an inherent fear, reflecting a type of phobic reaction regarding visualization of a woman’s sexual organs? The latter brings to mind what psychoanalysts referred to a s “a dentate vagina”. It is understandable how this aversion to woman’s body could shift his eroticism to that of a man.

These two Holtzman inkblot examples involving Content analysis illustrate the validity and usefulness of the HIT to evoke sexual symbolic responses. In uncovering the complexities of sexual function, the examination of imagery projected on inkblots, enriches that from other more superficial sources. A reader who is interested in reviewing the remainder of his responses may study these in the HIT book entitled “Inkblot Perception and Personality (Holtzman et al 1961).

It would have been worthwhile for comparison purposes, to have had an opportunity, to view such a subject’s overall Rorschach responses as well, it was reported that a number of overt homosexual responses were projected on the Rorschach. Yet for sexual assessment, the psychotherapist, who obtains free associations to the Holtzman series, has a major advantage, since there are many more stimuli cards. For any sexually preoccupied individual viewing this larger series, the probability would be higher, that some of the ambiguous array might more closely match preconceived sexual fantasies and trigger more relevant responses. This is also consistent with Dr. Holtzman’s Foreword where he mentioned the value of Content Analysis in assessing sexual imagery otherwise not disclosed in face to face interview.

Increasing the Number of SIS Stimuli:

This projective principle was expanded on, with a few of the SIS stimuli, which were purposely designed with subtle sexual structure that was suggestive, but not pornographic. Such embedded content provides a useful clinical interview aide, for those with sexual and/or reproductive problems.

As an example, a case history report in this book involves an adult woman being treated for Major Depression. She was allowed to complete the Booklet form of the SIS-II, in the relatively tranquil atmosphere of her home. When she was seen the next day for review of her responses, she exclaimed cheerfully “Dr Cassell …you must have designed the test just for me…I feel a lot better!”

She explained that as a teenager, she had been unsupervised, and sexually active. She had had multiple miscarriages, but never told anyone or effectively, subjectively processed her fears, guilt and remorse. Yet the SIS triggered the release of this highly stressful material. She then was able to independently process, with her now cognitively higher functioning mature brain, the deep seated PTSD memories.

This was totally unpredicted, and consequently a surprise. It prompted my deeper appreciation of the potential therapeutic releasing power of the SIS technique, totally independent of the therapist’s physical presence or immediate assistance. Many other illustrations of this phenomenon have been observed, especially with the electronic versions. These more readily can incorporate technological advances in computer based artificial intelligence and robotic treatment.

Robotic SIS Intervention:

In spite of the inherent scoring problems involved in the quantification of SIS responses, developmental work is currently underway involving “artificial intelligence” and “Robotic” cognitive/behavioral treatment. This involves establishing a computerized data base for individual types of content, supplemented by quantification of the various categories outlined in an earlier chapter. This will include normative data, as well as that derived from assessing individuals suffering from discrete clinical syndromes.

Two clinical examples, where projective technique can be useful to busy practitioners, will be mentioned. The first involves subjects who suffer from severe mood swings, but mask these with a variety of symptoms, symbolically detached from emotions. The second involves those with Conversion disorders, whose somatic symptoms pose physical diagnostic problems for physicians.

Next, an example will be briefly outlined, illustrating how robotic technology may be incorporated into treating members of law enforcement or the military, Such professionals have occupational exposure to stressful situations, which may precipitate PTSD. As part of their treatment planning, it can be helpful for them to experience at lesser intensity, protectively released memories of the original stressors, in a supervised therapeutic setting.

One version of the SIS under development specifically includes stressful scenes, in an ambiguous way. Upon completion of the initial viewing process, the treatment team then can establish with computer programming, a custom made follow-up program to desensitize the victim’s memories using Behavior treatment principles. This involves the repetitive presentation of the “Most disliked”, or the particular SIS stimulus which brought to mind PTSD imagery.

In the robot, this pre-selected visual stimulus is followed immediately by anxiety reducing nature scenes. Thus theoretically, while the neurotransmitters released by the PTSD “after imagery” are still present at nerve endings in the visual cortex, those healing ones released by the relaxing scenes, can serve to chemically restore the PTSD memory circuitry to healthy levels. In a robotic like fashion, on subsequent reconditioning exposure trials, controlled by computer programs, the clinician need not be present. For optimum therapeutic results, this brain reconditioning approach should be supplemented with cognitive psychotherapy designed to correct erroneous thinking related to the original stressors.

Reexamining Rorschach and Holtzman Content Scoring Categories:

A theoretical model relative to scoring by simple mathematical “addition” originally was conceived in the 1960’s. This was formulated after analyzing data from summing SIS responses denoting the heart, derived from subjects with psychophysiology cardiac symptoms. While it was known, that their heart imagery was linked to anxiety, no direct mathematical relationship was found by summing anatomical responses denoting the heart. Rather, a curvilinear statistical relationship was found. It was then recognized that “sensitization/repression” opposing factors could render the simple mathematical addition of content identical responses invalid.

This type of contaminating mathematical relationship, possibly might account for certain validity problems resulting from Rorschach and Holtzman summation scores. Perhaps, for subjects experiencing somatic symptoms, the same curvilinear type of relationship, as with the SIS might be operating. Conceivably this could render summation scores meaningless, for the comparable category of Anatomy. For these people, their anxiety linkage to related painful somatic structures could also affect the relative competitive forces of sensitization-repression affecting image surfacing in projective awareness. Perhaps as well, the same contaminating principle could relate to the “Human” and “Animal” categories that had been traumatized by abusive people or vicious animals. Clinical investigators who rely on either the Rorschach or Holtzman projective procedures are challenged to consider this possibility.

Art Communicates Pictorially Inkblot Imagery:

A basic scoring problem concerns the inherent subjectivity of using language. Most cultures are highly limited in emotional descriptive words capable of communicating the affect loaded inkblot evoked imagery and therapeutically releasing the stressed subject‘s “Inner Cry”. To access this more effectively in clinical situations, a symbolically trained SIS clinician may choose to supplement the interview with drawings of the inkblot evoked imagery - “a picture is worth a thousand words”.

Professional are Human Too!:

Any professional who clinically studies inkblot imagery in serious mental disorders, is empathetically exposing the brain’s visual recognition centers to bizarre affect charged imagery. This can predispose empathetic clinicians to occupational induced secondary PTSD. Sometimes such external imagery can interact in a negative way with the examiner’s own memory storage of stressful past events.

With inkblot projective procedures that trigger the release of inner suffering, this psychologically “toxic” factor, is much more likely to be operational, than with the non-projective psychological tests. Moreover, the professional who is blind to certain types of past personal symbolic imagery, will tend to avoid recognizing the significance of similar symbolism. This is an occupational problem which partly accounts for the difficulty in the general acceptance of projective techniques.

Just as psychoanalysts are required to have personal therapy, the same might well apply to clinicians using projective inkblot techniques. Readers are advised to study the illustrative cases which follow with caution. The authors hope that most will recognize that the benefits far outweigh the risks.

Clearly the above outlined Rorschach and Holtzman scoring systems have considerable clinical and research merit in regard to their statistical based normative data. However when they solely employ mathematical scores assessing for example “form, color and movement”, they not based upon fundamental principles projection. Theoretically when arbitrary categories of indices are scored to refer to them as a “Projective tests” is a misnomer.

Consider the underlying mechanisms when a test subject views inkblots utilizing the powerful pulling power of projection and then verbally responds when examining an inkblot. Initially “light energy” from the physical outer world falls on the viewer’s retinas. Within the biological organism neurochemical excitations arise and then are electrically transmitted by the optic nerves to higher brain centers involved in the yet to be scientifically understood process of “seeing”. In this conceptual model this end process involves a flow of visual imagery. Unlike inspecting a highly structured object in the physical world, the ambiguity of inkblots tends to cause a flowing and fluctuating experience in conscious awareness. To further distinguish the body/mind process of projective “seeing” in clinical applications, the evoked imagery is more likely to have affected charged disturbing linkage. Since many higher brain functions involve “neural inhibition”, this disturbing material may be blocked from cognitive recognition. Even if it is not, for reasons of social acceptability the viewer may avoid honestly reporting what is seen and felt to the professional examiner writing responses.

When the professional reviews what is written systematically utilizing a one of the “objective” scoring systems described earlier, certain fundamental scoring problems can arise in clinical situations. This is particularly the case in certain psychotic situations where there is pressure of speech, incoherence etc. Another example involves conditions arising from severe trauma. In these an inkblot may stimulate brain centers recording stressful memories in either a photographic like representation of the original stressor or stressors, or a symbolic representation as present in PTSD dreams. In all of these instances it may be highly problematic for the examiner to codify the flow of descriptive words in an “objective” scientific manner. In other words, the scoring process becomes vague and potentially “invalid” because of the inherent subjectivity of using language to communicate visual symbols.

Wayne Holtzman tried to overcome such fundamental quantification problems by basing his indices on one response per card. Obviously this makes mathematical sense for obtaining normative data. However, in many clinical situations such as those mentioned above, it is virtually impossible to do so “objectively”. How does the examiner determine where the descriptive termination ends of the initial verbal response ends based upon a flow of emotionally linked words describing symbolic imagery?

Our clinical application of content analysis attempts to answer this question while avoiding some of the other above outlined problems. The conceptual model envisioned focuses on the cognitive content of projected images, as well as their relative affective charge. The first part of this two pronged approach has a long history in the psychoanalytic literature. The second incorporates the responder’s own subjective rating of the emotional linkage or affect valence of the responses. This additional information is obtained by asking the responder to select the three “most liked” and then the three “least liked” ones.

In theory the former are considered to reflect positive emotional linkage of imagery. The subject matter of these responses is initially introduced to reduce test anxiety. As will be illustrated in subsequent case histories, these are more likely to relate to unresolved stressful material. Sometimes this symbolically hidden material is outside the subject’s immediate recollection and guides the psychotherapist in treatment planning. While changing the traditional order of detailed enquiry undermines to a degree the comparative validity of normative data, the trade off in therapeutic power is usually worth it.

Whenever possible, an attempt is made to further clarify the meaning of inkblot stimulated projected responses with clinical data from other rich symbolic sources. These include the symbolism in dreams, non toxic visual hallucinations day time PTSD flashbacks, pathological somatic imagery projected onto the responders own body image, transference distortions in perception of the psychotherapist etc.

The Inkblot Tests (Rorschach, Holtzman and SIS) employ mainly two methods of interpretation - Clinical and Research. Whenever a protocol is to be interpreted for clinical purposes, interpretation of the responses is essential. If the interpretation is required for research purposes, the total number of responses and percentages of various indices and Rejection of images need to be determined. It follows mainly two types of analysis:

It emphasizes on the analysis of various indices, such as number of responses(R), number of human, Animal, Anatomical, Sex, Popular/MT, Movement, and various indices in Determinants and Content categories. These indices are established for evaluating a series of mental constructs in various normal and clinical groups. The prognosis is estimated to be more guarded if the number of Rejection, along with the Pathological responses becomes elevated.

Content analysis is given more emphasis in interpretation since it frequently helps to bring out the unprocessed unconscious material. What is seen through the response profile, along with the affect linkage, may have direct or symbolic significance either in the present or in the viewer's past. It is quite analogous to assessing such material as the in-depth study of dreams. While the professional's own theoretical frame of reference will strongly influence the interpretative process, it is the authors, viewpoint that in most clinical therapeutic situations, content analysis for any given individual is a richer approach. Several Clinical cases are illustrated applying Content Analysis for understanding the power of inkblot instrument and outcome of therapeutic intervention.

Several clinical examples follow:

Stimulus Plate SIT-5: Butterfly / Contoured Bilateral Symmetry

The case examines how SIS-I, SIS-II and Rorschach imagery project associations to past painful body events. The three tests were administered and the interpretation of the tests is discussed in length.

An internist for pain management referred an adult female. She had a history of severe recurrent migraine headaches. The referring physician was concerned about the analgesic medication (Demerol). It was his impression she was experiencing psychological stress from moving to a new state. When initially interviewed she related that her painful headaches indeed seemed worse since her recent move to a new place. She denied mental problems. Mental status examination revealed an intelligent, middle-aged woman with some hysterical features but who was essentially intact. She showed no gross evidence of thought disorder and denied auditory hallucinations. Initial diagnostic impression was conversion hysteria with migraine headaches exacerbated by the stress of moving to a new place. The treatment plan specified psychotherapy to improve coping skills and reduce stress and hypnotherapy for pain control.

She avoided the spinal content, instead seeing a “screw on top of an awl”, disguised phallic symbolism. Moreover, she may have repressed the spine as well. She does not want to be independent and stand on her own two feet. An awl is a tool to make holes in leather or wood. Finally, near the top she projected another eye, perseverating this theme.

B 17: She gave a normal response. On substituted “a wrench” Her second association, “a carnivorous sea creature,” reflected symbolically her negative view of phallic imagery. An oral aggressive quality is readily apparent.

B19: She saw “a sunny day or intense passion”. This is a positive response associating the sun with warmth and emotion. She expresses herself as one who is capable of passion generally but not directly or overtly sexual, love more than sex.

B 20: Ordinarily seen as the brain, she saw “an atomic explosion.” Her defensive symbolism served to repress her brain an area she associated with her inner turmoil.

An atomic explosion suggests the magnitude of her rage as in A18. Her second level of imagery came closer to reality structure in that she saw “a wig on a Styrofoam headstand with a rose attached”. She allowed herself to see a head but not a brain. Her dream content suggested some degree of splitting that subjectively noted her anxious brain fixation.

Her response to B4 evidenced a cognitive disorder.

Her response to B21 was consistent with her aggressive feeling and previously detected catharsis of guns

B 12: She saw “a gun that has exploded”.

B 22: She saw “a person dead in the middle of the road”. It was consistent with the theme of body destruction and helplessness.

B 23: Instead of seeing anatomical chest structure, she saw “a ladybug. She has broken the rifle of a would-be killer.” The response of a diminutive female figure (lady bug) with the power to break an attacker’s rifle (phallus?) is strongly defensive symbolism. It reinforces the optimism and positive orientation of a rifle.

B 24: She saw “a curly mustache” and secondly “a two – headed snake.” Her first response, to a masculine structure may symbolize her perpetrator. It may also symbolize the male genitalia, the moustache as pubic hair, and the nose as penis. This seems likely since the next association was to a snake, a well-established phallic symbol.

B 25: She saw “An eagle with a crystal body and snakes at the end of its wings trying to see the future in the crystal. It looks like a baby eagle”. The baby eagle signifies regression. She lived at home and was never separated from her family.

The snake imagery from B24 continues phallic imagery. Metaphorically this may be a variation of the Little Red Riding Hood theme of the virgin in the forest, a baby bird with the snake near at hand on its very wingtips.

B 27: Evoked a typical response.

In the first hypnotherapy session, she proved to be an excellent subject. She was able to learn and apply relaxation techniques and imagery to reduce her headaches. Over the next several months there was a dramatic reduction in her pain and need for emergency room visits. However, as her treatment progressed, her case became much more complex. Following the first hypnotherapy session she recalled a long and traumatic period in her childhood involving sexual abuse by her father. She also became aware of amnesic episodes when she would suddenly find herself outside a bar dressed in provocative clothing. Eventually she reported being aware of voices in her head telling her to do socially unacceptable things. At that moment, her voice and behavior changed, adopting one of several multiple personalities. In one therapy session she suddenly spoke in a deep, threatening masculine voice as she assumed the identity of one of her early male abusers. Eventually, she recalled a history of terrifying child abuse in a religious cult where she said she witnessed human sacrifice, mutilation and the burning of babies.

She was administered the Rorschach followed by the 20-card of the SIS-I. Her Rorschach responses were:

Card I “A face with eyes and nose. Part of this smile is covered by a black mask.” Here content analysis revealed she has internalized the image of a masked man. Historically, this represented the male leader of the cult that abused her in childhood.

Card II: “It’s a face. Above the eyes are red figures. The head must be hurting. He is shouting out in pain.” The person perceived represented a direct projection of one of her male altars personalities who experienced the painful headaches.

Card III: “It’s the figure of a person with long black arms. His head is split in two. The eyes are covered with dark sun shades”. In this response sequence, she continued to project one of her male personalities. Seeing the “head split in two, is interpreted as a direct reference to the “splitting” intensity of her headaches at a somatic level. At a psychic level it reflects ego splitting one of her male personalities.

Card IV: “Just a very dark looking mask.” Here she was able only to see blackness with weak, undifferentiated mask-like form.

Card V: “A butterfly. Black. Sad to see a butterfly all black.” These are popular response but with added depressive content mirroring her own feelings of sadness and depression.

Card VII: “Two elephant faces not looking at each other. Above their heads is another butterfly.

Card VII: “Two pink cats walking down. Blue butterfly with square wings”.

Card IX: “Two narrow eyes being hidden by pink, blue and orange masks. The eyes are sad. He wants out.” The theme of a masked person recurs with added content suggesting depression and a wish to escape or relieve the depression. It represents one of her repressed personalities that is sad for lack of expression in her behavior. She responded in a brooding, threatening masculine voice.

Card X: “Every object has a partner, two of everything.” Aspects of the inkblot are personified and split in two.

Her responses to the 20 SIS-I cards:

Card 1. “A spook with distorted eyes. Face of animal with eyes and horns. Red looks like birds”. The spook represents the face of a past abuser. She was fearful of birds. In a phobic way she insisted upon the removal of a picture of an eagle from the interviewer’s office.

Card 2. “Somebody’s head has been cut off. Somebody laughing, a get even type of laughter”. She viewed a mutilation scene involving the motive of revenge. This is consistent with childhood cult abuse and certain of her murderous personalities.

Card 3. “Two people. A man and a woman. The red blotches represent pain, close to the chest and heart, hurting pain”. Her perception of the red central objects as pain close to the chest and heart represent a direct projection of her own conversion pain, related more to her chest than her head.

Card 4. “A person, probably a male, and a red apple”. She again projected male identification. For her, female body images were to be avoided because of their threatening association to her long childhood history of sexual abuse.

Card 5. “A swimming turtle, two dots, little children and a heart.” These are unremarkable responses.

Card 6. “An animal trapped in an enclosure. They can’t get out. A person standing on a heart. The reference to an animal trapped reflects a statement of how she feels when multiple personalities speak to her in her head.

Card 7. “An animal sitting with feet. A llama. The heart is red. Some poor animal hurting”. She projected her pain onto the image of the animal hurting.

Card 8. “Seahorses”. “A rib cage and heart”. A heart split in two instead of one. Her reference to the “heart split in two” described her own mental splitting.

Card 9. “Two masses, inside, joined by something in common. The bottom looks like a knife.” She repressed the anatomical content because for her urogenital imagery is especially threatening. Her projection of the response “knife” is clinically significant. Prior to viewing the SIS image she had awakened from sleep on one occasion with a knife in her hand. She was completely unaware of how or why she picked it up. During this phase several of her personalities were both suicidal and homicidal.

Card 11. “Red colors”.

Card 12. Someone trapped in a red mask. Two faces on side, one angry, the other dazed”. Her responses continued the theme of being trapped and masked. She projected anger onto one face and confusion on the other.

Card 13. “ A beetle chopping away".

Card 14. " A dark demon with two eyes"(top). A tiny cross at the bottom. A face with no eyes or eyebrows". Because of her past sexual abuse she repressed vaginal imagery. Non-anatomical symbolism defended against this aspect of herself and involved negative connotations. The dark demon symbolizes certain of her personalities, which act out sexually. After such episode she would find herself standing outside a bar "dressed like a hooker” and be entirely amnesic about her sexual behavior. Another of her personalities was flirtatious and would attract a large following of men at cocktail parties.

Card 15.“ Little faces staring up at each other. Eyes. The base support” (bottom). She repressed the spinal content because of the association of the spine with sexual activity during intercourse. Non-anatomical defensive material represents projecting of the faces of her multiple personalities.

Card 16 “A face with two eyes and a nose”.

Card 17. “A skeleton part. The vertebrae and pelvic area. There is also a face with white eyes and a mouth.” She added the comment: “I don’t like it. It makes me depressed.”

Card 18. “Mountain cliffs and a man looking over people standing”. The people standing reflect her multiple personalities.

Card 19. “Masks, carnival, Halloween.” The mask theme continues. She introduces the concept of Halloween, with implications of monsters, ghosts, frightening costumes, and a cult ritual holiday she may have associated with her traumatic child ritual abuse.

Card 20. “The Devil himself, eyes and horns, the mouth wide open like he wants to say something or scream at someone.” One of her inner personalities represented the Devil. It was his screaming at her that frequently produced her headaches.

The Rorschach and 20-card SIS were later re-administered. The second administration of Rorschach yielded the following responses:

Card I. “Pumpkin face, Halloween type faces. I like it. Feels like I’m being laughed at. A bad feeling of being watched. I see two birds on either side of a pumpkin face”. At this stage of therapy she was working through her incest trauma. The multiple personality disorder had not yet been diagnosed.

Card II. “Face of a man. Eyes are red, mouth white as if opened, tongue hanging out – it’s red”. Her responses again reflect a threatening man’s face. It was reasonable to postulate it represented the face of the perpetrator of her incest trauma, her father or other adult male cult members.

Card III. “Two female images each holding on to someone’s head. Looks as if they’re pulling on the head. Looks like a red heart or two hearts joined between the females. On each side of the female’s head are red falling objects, falling down.” She avoided male content, possibly defensively because of how males have been threatening to her. “Pulling on the head” may reflect past abuse or it could depict the psychic forces splitting her personality and figuratively pulling her head apart.

Card IV “At first I see a monster face coming towards me, black and scary. Next I see two boot-type shoes on either side of a common object. At this stage of her therapy, her multiples were closer to the surface. In the projective test situation she was unable to view the stimulus objectively .It became animated and moved towards her like in dream imagery. Her ego was less intact and she was moving into a border-line or psychotic position as the terrible extent of her past abuse was beginning to emerge. In retrospect, this brought to mind Freud’s original comments about analyzing a patient with hypochondria cal abdominal pains. When terrible problems come into consciousness he mused philosophically that it might be more humane not to pursue psychoanalysis and leave the patient with less physical suffering, the lesser of two evils.

Card V “Black butterfly, but I also see two objects joined in the middle each wanting to pull away. This represents a direct projection of her early splitting her terrible past from memory.

Card VI “The smaller object at top has to pull the two larger objects on the bottom. Both of these two larger objects are joined in the middle by a common body. The object on top would like to be rid of his companions”. The theme of splitting continued with symbolic representation of the great psychic tension it causes.

Card VII “Two Indian type girls looking at each other. They each have one feather on their head. They are balancing on the edge of butterfly wings. They don’t want to be together.” The theme of splitting continued.

Card VIII “I see two pink rats walking over on three sets of objects or bodies. In the bottom object I see a scary yellow gold face.” The “set of bodies” reflects the early stage of her ego breaking into multiple personalities.

Card IX “I don’t like this picture, it frightens me. It’s all messed up like me.” She acquired more insight into the extent of her past trauma and resultant psychopathology.

Card X “Everything in this picture is connected by some common link, I see different objects like two gray insect-type objects at the top looking angry at each other. Two blue spiders. Two Green sea horses. I see blue in the middle, a pelvic type skeleton. There is, however, in the middle an orange wishbone type object. Everything’s very scattered.” This response symbolized the anger and conflict between her inner psyche structures.

After taking the Rorschach she completed the 20-card SIS-I for the second time and these were her responses:

Card 1: “Distorted face, twisted white eyes, crooked, two red hens, and the face are sad.” This response parallels her earlier response.

Card 2: “I see red lips, laughing man at bottom holding his arms wide open. Looks like a bird flapping wings at top of picture.” She failed to make a gestalt of the Inkblot configuration. The splitting reflected inner psychic fragmentation. The theme of being laughed at or tormented continued.

Card 3: “Two objects, one man the other female, red hearts in between the two, sharing.” This response was more positive. The couple was sharing and there is less pain consistent with less conversion pain.

Card 4: “Red apple at top, male figure at bottom, the male is smiling.” She failed to recognize the female figure, consistent with a poor feminine identity and low self-esteem. She was more comfortable talking with men than women. As therapy progressed it became apparent her mother knew of the longstanding sexual abuse. She recalled hearing her mother’s footsteps near her bedroom door when her father was abusing her.

Card 5: “Looks like a black turtle with red heart, two infants on either side. The one on right is upside down. Two red dots above the turtle look like red eyes”. She continued to euphorize her reaction to red color. Eyes are consistent with her paranoia.

Card 6: “Bottom is a heart, red, with a red man walking on it. Two doves connected or trapped that can’t get out or escape. Two reds on top are eyes looking at me.” These responses projected two of her inner personalities seeking expression. The paranoid theme continued.

Card 7: “Large red heart surrounding in the neck of a llama that’s all dark.” This response reflected her clinical improvement. At this stage of her therapy she experienced less physical pain and wasn’t taking analgesic medication as frequently.

Card 8: “Two dark seahorses eating on someone’s heart. This response reflected the degree of suffering from her childhood history of abuse.

Card 9: “Two bodies connected to a lower body with a knife at the end of lower body.” She repressed male imagery because of its threatening qualities. The knife relates to human sacrifice by the religious cult.

Card 10: “Red lips at the top, blood running from lips onto a foreign object. This represented more direct association to her emphasis on red.

Card 12: This card evoked no response.

Card 13: “In the center I see a black scary object looking at me.” This response associated with one of her internalized “bad” objects.

Card 14: “A little girl in the center with arms open”. She repressed the female genitalia, the area of her past trauma. It showed age regression to the time of the incestuous abuse.

Card 15: ‘Looks like stacks of bones, a spine?” She had less anxiety and appropriately identified the spine. Experience with a variety of clinical populations suggests that there is less somatic repression and less conversation pain as a person focuses from body to psychic conflicts.

Card 16: “Two faces, dog faces, sticking their tongues out at each other.” This symbolized aggressive feelings.

Card 17: “Black atomic cloud with a sad face, with white in it.” This response reflected hostility and sadness.

Card 18: “Scary face with mouth wide open.” This symbolizes a threatening internalized object.

Card 19: “I see a face again with long eyebrows, mouth open, coming from behind two human type objects trying to hide.” Threat theme continued.

Card 20: “This is also a scary, angry face, with mouth wide open. There is a wishbone above the head.” It is more of the threat theme.

Four years later she was again given the SIS-II booklet form. It was apparent that her headaches were not migraines but rather conversion phenomena arising from conflict between her various personalities and emergence of past traumas to full consciousness. Viewing certain SIS images precipitated and intensified her head pain.

She saw A5 as “a monster with giant arms, a heart with a cloud above. It makes my head hurt and gives me an uncomfortable feeling.” On A10 she responded: “It makes my head hurt. It’s a face. I see eyes and it leaves me with a painful feeling.” For image B11 she projected “a nose with sinus pain”. She repressed the picture of the brain on B23. Onto this painful region, which she perceived as the nerve center of her mental conflicts, she substituted “an atomic bomb explosion”. Symbolically this reflected her terrible past traumatic neurosis. Despite earlier brain repression, on B30 she saw “a brain divided up” directly associating her multiple personalities. Also relative to her multiple identities was her response to A13 as “lots of hands reaching up for help” and A14, “monsters fighting over a heart,” the effect of her destructive personalities. On A18 she saw “a skeleton skull with the devil inside, scary.” In a follow up interview she recalled this was a direct projection of “the evil one”, one of her more powerful identities. On A 24 she saw “a group of people with arms connected”. In the detailed inquiry she related these to a group of five inner personalities who had gotten together to fight the evil one.

Some responses related to her trauma and sexual anxiety. Instead of seeing a woman on A7 she saw “a man with an apple above his head. On A20, depicting kidneys and male urogenital system she repressed the male sexual content and saw instead “two Lima beans attached by a hair.” For the spinal picture in A23 she refused to respond and said only that she didn’t like what she saw. She related A14 to the ritual abuse by family members and others in the cult: “The fetus, someone killing the baby”. She saw A27 as “A cut-off breast”. A partial determinant of her response to A14 was that she tried to abort her youngest child at four months. This occurred after her father, in a jealous rage, told her he didn’t want her to be pregnant by anyone else. Some of her responses reflected somatic concerns about areas other than the head. To A28 she responded. “Muscle tendon in pain”. For B13 which depicts the female pelvis she saw “three growths on the stomach” referring to colitis. This involved excruciating recurrent abdominal pain with diarrhea. It felt like her “insides were on fire.” For B17, which lacks somatic structure she saw "a heart" relating to palpitations, experienced when upset.

Interestingly, responses to the videotape version of SIS-II images accessed much earlier traumatic memories. B 24 elicited memory of a burning baby. She recalled that as a child she witnessed cult ritual mutilation, murder, and burning of babies. The video evoked more painful somatic symptoms (eg headache) and was more psychologically threatening than the SIS-I, the SIS booklet, and the Rorschach

Stimulus Plate SIT-1: Core Somatic Grief / Central Structural Focus

The SIS (SIS-I and SIS Video) and the Rorschach test were administered to a 42 years female patient (named X in the Case discussion). The SIS and the Rorschach were able to bring out her inner cry and depressive contents related to her father’s death due to cancer and her own recovery after cancer. SIS images have been found a powerful media to take the person back in time and creating hypnotic like effect helping the person in catharsis and finally proving to be an effective therapeutic tool. Responses given by the patient on the Rorschach and the SIS-I and SIS-II Video are interpreted using content analysis and psychoanalytic interpretations.

The subject of death has been explored from a number of standpoints (Kubler-Ross, 1969). When a parent dies, the psychological impact ordinarily is very great (Myers, 1986). Sometimes the grief may be prolonged over the course of several years (Doka, 1989), resulting in Major Depression and various conversion reactions involving the experience of somatic pain.

There are many stages in the grief process. One involves the appearance of the deceased person’s body or aspects of the body in the individual’s dreams (Von Franz, 1984). This is one way for the individual to experience spiritual and psychological contact with that individual and to deny the pain of the loss so that sleep can occur. The dreamer, when awake, realizes that it is “just a dream”, and will then feel the emotional discomfort and continue in the normal grieving process. Occasionally- especially at night-the images of the person will spill over into conscious awareness in the form of hallucinations when the deceased person will appear as a ghostlike figure and sometimes talk. The lay public has referred to these hypnologic phenomena involving images of the departed loved one as “ghosts”.

Images of the deceased person’s body may be projected onto inkblots (Cassell, 1980) and video stimuli having human and anatomical content. This process will be illustrated by presenting the case history of a woman, who had lost her father several years resulting in depression, and required antidepressant medication earlier, resulting in depression, and required antidepressant medication. Psychologically, she closely identified herself with him in her own body gestalt. She had developed painful somatic symptoms in her chest, mimicking those, which he had experienced in dying of cancer of the lung.

A transcript of a video interview completed with this grieving person follows:

X: Miss him. I could always talk to him. He made me feel good. And even now I sometimes still feel it was my fault that he was sick.

X: He had cancer and it went into his bones and then he died shortly after we got back. We were gone when we found out that he had cancer. And we got back to home in Aug 82 and it just wasn’t my father.

Dr. B: Yeah.

X: He had changed quite a bit from the chemotherapy and that.

X: Well, when I first saw him he was just, he was sitting in the corner of my mother’s kitchen and he was just little thin old man with hardly any hair. He couldn’t talk because he’d had a couple strokes and he had a hard time with that.

X: He was 56.

X: Especially when I saw him the summer before and he was. We had gotten closer and I guess I could just talk to him.

X: Yes, he looked like my father and not like this person that I saw when we came back.

X: Secure.

X: I would feel very upset, umh some I would really kind of feel like I was, when I woke up and found that he wasn’t there, that was the dream and that the dream I have of being with him was real.

X: Yes, sometimes I’ve walked through the malls and might have gotten a glimpse of someone, a gentleman walking or shopping and I would have to look again because I thought it was my father.

X: It kind of scared me a little bit but they were high but when I realized it wasn’t my father they were.... I felt very bad.

Dr. B: Yes. I appreciate your sharing. I know it’s very painful. It will help to continue in getting some of the grief out. One of the things we noticed was when you looked at these ink blots you saw things resembling your father. And at this time I am going to have Dr. Dubey go over the results of the Rorschach Test with certain of the cards so I’d appreciate if you would share with him as well, O.K. Thank you.

X: It’s just.

X: It just reminds me of the cancer cells eating him up inside and he is having a hard time not being able to speak because of the strokes.

X: Just the cancer and the blood. Wondering where the blood went because my father was cremated.

X: He was my son and my mother, you know it just feels like I try to talk to my mother and I try to do what she wants me to do and I try to please her and to please my son too and I can’t do it. I’m having a hard time.

X: Well, my son he tries sometimes. He sticks up for me when he knows I’m being pushed into a corner. He has this feeling. My mother, I love her, but I have a hard time getting her to stand by me.

X: She thinks it’s all in my head.

X: I’m just ashamed of myself because I can’t seem to do what everybody wants me to do and like I said before I feel responsible for my father’s death. For being bad when I was younger. And I just don’t want anybody to see...

X: Because I feel if I had been a better daughter. I just feel that they took it out on him to punish me and uh for being the oldest I just feel like I didn’t set a good example for the other kids but yet I was treated like the youngest a lot.

Dr. D: So you think yourself as a bad girl and your father was being punished for your mistakes.

X: You see I came up here. We were in the States and I came up the summer before for vacation. I was under a doctor’s care there and I was having some problems and I didn’t spend the time I wanted to with him then. And we were getting closer and closer together and I had to leave. It was recommended by a doctor that I go back to be with my doctor there so I had to cut my trip short and leave him before we really got a chance to get a lot of things said.

Dr. D: On card X you perceived “This is an explosion. There is something coming out of mind.” What makes you to think like that?

X: It makes me think of me. I keep a lot of things inside. I don’t yell that much at my son. I just let things that happen to me. I keep inside and then when it reaches a certain point I just lose it. And I try to talk and explain what’s going on and I can’t because I’m so nervous and crying and then when it’s over I feel ashamed. I feel like I’ve done something wrong.

Dr. D: And by seeing “something is coming out” might be giving a sort of release, release of tension.

X: By not keeping it in anymore. By finally saying something to someone. Like I say I have a hard time because I just start crying and shaking and I can’t get it out. I just sometimes feel like I want to explode because I can’t take any more.

X: Yes.

Responses on other cards of the Rorschach were normal and clinically not relevant for interpretation.

X: It’s just coming to get me. I think about a lot and I, like I say I’m afraid of dying. And it’s coming.

X: I’m afraid that it’s gonna come very soon and I worry about my son when it happens and my husband but mainly my son. I don’t feel I have done very well as far as health goes this year and I’m scared. I don’t want to die right now.

X: It’s mine, my father’s you know everything. All the problems that I’ve had where I’ve lost blood and my father losing all of his blood somewhere and it’s just all together.

X: Through surgery and death.

X: Surgeries that I’ve had and death of my father.

X: Well, it just looks like the gate of hell. The teeth are the gates that are opening that you walk through. The eyes are watching you to make sure that you do come. It’s like it’s waiting for me. That’s where I’m going to go because I wasn’t good.

Dr. D: It’s very painful.

X: It’s scary.

X: It’s the mouth opening up and as I go through closing in on me.

X: I’m afraid that’s where my father is.

X: It’s the pain eating inside. The pain that my father felt. The pain that I feel when I need him and he’s not there.

X: It’s like a disease.

X: Cancer.

Dr. D: Yeah.

X: I’m scared of cancer. I had it once before, got over it but it kind of. It’s like, first they said the cancer is looking good, that it was getting smaller and then all of a sudden he started getting bone pain and it was in his bones.

X: Right now they just look like little people that are trying to take him over. They want to get in and spread more.

X: Just a disease.

X: Well, the child is used to having just a mother around and now he had to learn that the mother has met someone and that they are going to be husband and wife and that the mother has to build her life around the husband and the child doesn’t understand it because he had always had the mother’s attention.

X: My son.

Dr. D: Yeah.

X: Yeah, it was just him and I for quite a while and then I met my husband and I tried to please, you know my son and my husband. It was hard. My son needed to build his life around us and you know. We had problems because I would be upset when my husband would punish him. I would say things in front of my son.

X: Yeah, and I shouldn’t have. I should know. I just wanted my son to grow up and be loved. You know he deserves that.

X: It’s like the slow death my father had. I mean it was fast but yet it was slow painful. A person or thing is just laying there helpless and not being able to move. Say anything who ever once in a while open his eyes and look around and see that the family is there with him. And there is nothing he can do and he tries to speak but he can’t and he just slowly starts dying.

On image A2 you perceived “a bad life with lots of uncertainty”. Would you like to tell about this?

X: It does not know what’s going to happen next. And it has been a bad life, maybe not for me but I have put my husband through an awful lot and my son. Insecurity had made me afraid that my husband will find someone else. Someone, who is better for him, I give everything I have but I sometimes don’t feel that it’s enough.

Dr. D: On next image # A3 you saw “Its flower and beautiful” but later on you said that it’s a flower with roots and an insect is eating the roots.

X: That’s what it looked like.

X: It’s just that there are something that are beautiful and some people that want to destroy. And my husband is a very good man and sometimes I feel that I am dragging him down. So I feel like I’m the beetle eating the root because I kind hurt his career so.

Dr. D: It is very painful. Let’s go ahead on image A13. You have seen “man’s hand reaching for help”.

X: My father reaching from the pits of hell. My father wasn’t a bad man but he had problems and...

X: Reaching out for somebody to help him.

X: Sometimes.

Dr. D: Yeah.

X: Then when I think back on some of the things I did, he didn’t.

X: My father being torn apart with cancer.

X: Being eaten up with cancer.

X: I had to have a hysterectomy because I had cancer and my sister was pregnant and she didn’t want to have any more children and she went and had an abortion.

Dr. D: Oh! I am sorry.

X: And to me this child that never had a chance to live and that she could have more children and I couldn’t.

Dr. D: Take care. On image B2 you have seen “cancer eating up all good cells”. So again you are thinking...

X: My father.

Dr. D: Let’s proceed to image B3. You perceive “Two people, man and woman sitting in a house on fire”.

X: It’s, I don’t know it just looked like two people that were sitting there and that really didn’t realize what’s going on around them.

X: What’s going on? It’s like they’re not there.

X: I feel that way sometimes.

X: My father had lung cancer and the last chest x-ray that had it didn’t look too good and it just scares me.

Dr. D: I am Sorry.

X: ‘Cuz I don’t want to die of cancer. I don’t want to go like my father did.

X: Cancer cells in the brain.

Dr. D: Last image on SIS video B 22, you saw “a man lying down with a bad pain”.

X: Bad pain. Fire in his stomach. It just looked like there that his stomach was on fire.

X: It was like fire, you know the smoke and uh the pain and my father was hurting very badly in the hips and around there.

Dr. D: You have not listed the three images which you liked the least.

X: I wasn’t really able to. It was hard because the cards they really make me nervous and they’re hard for me and I didn’t like them. Very few did I...I just didn’t like them. I felt agitated, I mean not agitated but nervous. I just wanted to forget about them.

Dr. D: Hope it has helped you in releasing lots of emotions and sad feelings.

X: Well they are.

Dr. D: It’s very painful.

X: I guess nobody could prepare you for that. But then when he went in the hospital the last time I stayed there day and night, all of his kids did. We slept on the floor and in the halfway. We all stayed there with my mother until it was over.

Dr. D: Thank you for sharing your feelings with me. We’ll be meeting again.

Dr. D: I use both the tests SIS and Rorschach clinically. The SIS provides more vital information and it is a quick test for diagnosis and screening. The SIS is backed by theories of Body Symbolism and Inner Cry (Cassell, 1980). The theories are very impressive and exciting. About 40 percent of cases in hospitals particularly in psychiatric set up have psycho manifestation, and the causes are psychological in nature.

Dr. B: Exactly. A lot of people cannot verbalize their emotional issues and tend to somatize. In medical set up physicians and nurses who focus on the physical symptoms does not imagine the impact of such emotional issues. Many either do not have time or the training to work on the psychological issues is not adequate.

Dr. D: Yeah. And quite often I have found that people express their psychological problems through physical symptoms.

Dr. B: Yes.

Dr. D: So the test is very helpful in detecting the psychological problems, the inner cry of the patient as in the case of Mrs. X’s. The medicine (anti-depressant) may help her in managing physical symptoms and SIS images will help her in processing deep rooted emotional trauma. Her problem is probably because of her psychological/emotional attachment with her father, which she is unable to resolve after his death.

Dr. B: The anti-depressant medicine helps her to feel better symptomatically. The symptoms are removed and so on but it doesn’t get to the core difficulty, the grieving process and her irrational thoughts.

Dr. D: Exactly. As you have noticed that the SIS images have created hypnotic like effect and she started verbalizing with her inner cry. It helps in understanding the psychopathology of the case and releases tensions of the person undergoing the test. And you could notice her face; she was feeling released and cheerful.

Dr. B: She got relief. As time goes on, in my own career, I have moved from an interest in the diagnostic aspects really to the therapeutic and I am much more interested in the techniques that help people, which release feelings and help them understand themselves.

Dr. D: Many psychologists working in educational institution and not really trained in handling patients/clinic population do not believe much in inkblot procedure. They believe more in questionnaires because it does not require any training and sophistication in interpretation.

Dr. B: That’s right. It’s also true in this country that some of the authorities on Rorschach who give seminars do not see a broad range of patients anymore. They are so removed that they’re missing some of the richness of clinical work. I wonder if we could go through at this time and have you comment on some of the specific color responses. Please begin with her Rorschach responses and then SIS.

Dr. D: All four Rorschach cards # II, VIII, IX and X were very informative and effective in this case.

Dr. B: Yes.

Dr. D: She was very upset while viewing chromatic cards.

Dr. B: They carry the punch in terms of the affect.

Dr. D: She was unable to control her emotions and all through she was sobbing. She was crying like a child during the interview session.

Dr. B: Yes. So she really went back in time to the original loss of the father. So this pulled her back and facilitated release of the pent up grief.

Dr. D: Right. And it is really difficult to score such responses under closed scoring categories. For example, on Rorschach Card # VIII, she says “I feel like as I am in the center and two persons are pulling me from each other, and that one side is my mother and on the other side my son”. Such responses can be interpreted only by using content analysis.

Dr. B: Correct.

Dr. D: And this is how the clinician can hear the inner cry of the suffering individuals.

Dr. B: Exactly.

Dr. D: What she perceived is her real situation.

Dr. B: It makes it more real when you have a stimulus than just talking in generalities in an interview.

Dr. D: Exactly. And on Rorschach card # IX again she perceived “a person hiding behind and feeling ashamed like me”. This is true projection, which one can never imagine on questionnaires.

Dr. B: Yes.

Dr. D: And such feeling that “I have let them down, especially my father”. “I feel like I am a bad girl and my father is being punished for me”, is common in paranoid Schizophrenics. However, such responses are possible due to excessive unreleased grief and feelings of guilt.

Dr. B: Right.

Dr. D: And on the basis of such responses she cannot be categorized with paranoid symptoms.

Dr. B: That’s right.

Dr. D: Such responses can be explained only through psychoanalytic interpretation.

Dr. B: Yes.

Dr. D: She is blaming herself because she could not attend to her father when he needed her. It is her guilt feeling for not attending to her father during distress though her health did not allow her to attend to her father.

Dr. B: Yes. She was helpless.

Dr. D: She felt that as a child it was her duty to help her father whom she could not do and because of this she is calling herself a bad child.

Dr. B: So it is very important that the therapist ultimately go back and make these interpretations.

Dr. D: Exactly, this is what Dr. Piotrowski (1985) explained me during my visit to his home at Logan’s Square, Philadelphia in July 1985. He explained that do not give more emphasis on indices such as M, FM, C, Popular, and Form and try to understand the meaning behind the responses given by the subjects.

Dr. B: Yes.

Dr. D: Because after all, what is the purpose of psychological tests? It is only to understand the psychopathology of the patient.

Dr. B: We want information, which is clinically relevant to the therapy process.

Dr. D: Exactly, and that is why out of 62 images of SIS, I was interested only in a few images giving more clues.

Dr. D: The images rated as most threatening helped in understanding the psychopathology of the case. Such images depict specific body percept and traumatic situation which the patient has experienced in past. In fact it is not the 10 cards of Rorschach, or 20 cards of SIS-I or 62 images of SIS –II but the three most threatening images which will provide you signals to peep into the inner self of the subject.

Dr. B: Yes.

Dr. D: And we do depth interview to understand the causes of threat/repression.

Dr. B: And then in instances where there is somatic repression then only those that are relevant.

Dr. D: May be out of 20 cards you are interested only in five or six cards for depth interview / analysis.

Dr. B: Right.

Dr. D: Other cards you can leave aside.

Dr. B: And with the video technique you are not there so it doesn’t take that long to process such material.

Dr. D: Exactly. And even on SIS-I card # 20 she said “It is death coming to me, it’s hurting me. It is about to take me. I am afraid of dying”. Unprocessed grief comes like this.

Dr. B: Yes.

Dr. D: It is painful to imagine but there are many more such persons facing to cancer bravely.

Dr. B: Excuse me. In the book “Body Symbolism (Cassell, 1980)” the last chapter deals with death anxiety. And characteristically, as you know, people deny death as an issue. And we have a technique here on some of those death related cards you can introduce it clinically and deal with it.

Dr. D: Yes, she has projected the fear of death by giving responses such as “Gate of Hell” on card # 18. Further she said “I have to go inside-my father has already gone inside”. One can see the sort of fear and insecurity in her.

Dr. B: There’s a lot of rage associated with this. Part of the problem with her is that she hasn’t gotten in grips with her anger for her father for leaving and the way he died and some of the old childhood problems as well.

Dr. D: And on card # 19 she said “I’m going to die and my father died and may be in the near future something is going to happen to me”.

Dr. D: Well, she has maintained ego strength and attached with her son and husband, because of this the chances of suicidal is very less.

Dr. B: Yes.

Dr. D: She is aware of her medical profile. Her strength is still her consideration and caring attitude towards her family.

Dr. B: Yes. She has also a positive relationship with her husband and other people who love her.

Dr. D: And if the person has gone through such traumatic experiences, such responses are but natural.

Dr. D: While taking the questionnaire people have to restrict their choice to yes or no, true or false, agree or disagree. Most of the time, these questionnaires have cultural influence. Contrary to this you are free to project your feelings and emotions on inkblot tests. Somatic Inkblot Series is the latest and most powerful amongst the inkblot tests.

Dr. B: Yes.

Dr. D: And in fact, in one of my studies, I tried to find out correlation between Rorschach and SIS, It turned to be quite low, reason being the Rorschach measures the basic personality and is used as diagnostic test. The SIS is a diagnostic instrument and an aid to psychotherapy. It helps in understanding the psychopathology of the case. It further helps to peep into the inner deep and hearing the inner cry of the suffering individuals and you can get more information which is not possible through other tests. The SIS is not against the Rorschach test but it is further extension of the Rorschach. The SIS was also tried in India during selection and was found to be a successful instrument in getting the right man on job.

Dr. B: Yes.

Dr. D: So the SIS covers both the aspects diagnostic as well as therapeutic. The best part of SIS-II and video is its self-administration. It can also be administered in-group. It reduces test’s anxiety because the subject is alone while taking the test. It helps in true projection. The test can be taken even at home or while waiting for your turn in the clinic. And, because of these qualities, it is the best projective test.

Dr. B: And there are variations in the use of SIS test. For example, currently I am interested in administering the procedure at bedtime and seeking at what extent some of the images are picked up in the individual’s dreams by doing the interpretation of dream work the following morning.

Well, thank you very much. Dr. D. Your comments have been most helpful and I have learned a great deal from you in terms of your own experience with the SIS and sometimes one can get too close to a procedure but I think it has been very helpful and thank you.

We’ve had the opportunity to look at an individual who has lost her father and see how this has affected her responses to the Rorschach and the SIS both in the card form and the video. Hopefully this material, as time goes on, may be brought up in therapy in ways, which will help her express the inner cry and further move ahead in resolving the blocked grief. As an experienced clinician might well imagine, it is not just a matter of prying at the pain to release feelings. In addition, there needs to be definitive cognitive therapy in terms of helping her deal with some irrational thinking that she has relative to her pathological guilt. Similarly, she needs further insight into, how the sympathetic identification with her father’s deteriorating body image contributed to her converting the diseased anatomical imagery into repressed affect, leading to physical symptoms of chest pain and marked cancer phobia.

Stimulus Plate SIT-7: Exhibitionism / Body Boundary Perception

Aside from exhibitionism, the patient – a 28-year-old single painter – appeared to have no other major psychological problems.  His past behavior indicated that he had considerable difficulty in relating to women.  He denied release of sexual tension through masturbation – rather, when such feelings reached a peak, he impulsively exposed himself to women.  Although he had experienced sexual intercourse on one occasion, he recalled feeling quite ashamed about this.  In fact, he distinctly remembered imagining that someone was in the room watching the sexual act.  When questioned about his he indicated the observer might be God who was there to punish him for having sex outside marriage.

During interviews marked resistance was encountered in discussing body attitudes.  It was learned that he had doubts about the adequacy of his sexual functioning including fears of being sterile.  His sexual fantasies involved situations where he and a woman would undress for mutual exhibition.  However, at no time was sexual imagery in consciousness permitted to involve mental scenes of genital interaction between his body and that of a woman.  Related to this, his past family background was characterized by a puritanical home situation and marked sexual restraint.

Method of Projective Testing:

The SIS was conducted in the presence of a second investigator who observed the patient’s general reaction to the test situation.  The study was conducted under two conditions.  The first simply involved administering the anatomical pictures to the patient in a manner analogous to that employed with the Thematic Apperception Test.  The second concerned the modification of the individual’s consciousness through the use of rapid acting intravenous barbiturate sedation.  This was administered in a sufficient dose to experimentally induce a state of psychic relaxation to control anxiety thereby reducing the patient’s inhibitions in mentally processing the somatic images stimulated by the pictures.

Prior to viewing the pictures the patient was given the following instructions:  “I have here a series of pictures that I am going to show you one at a time.  As you look at each one, tell me everything. Prior to viewing the pictures the patient was given the following instructions:  “I have here a series of pictures that I am going to show you one at a time.  As you look at each one, tell me everything that comes to mind.  Although different things are seen by various people, I am particularly interested in what it reminds you of in viewing it.  Remember that there is lots of time.”

In order to obtain accurate records both interviews were tape recorded and later transcribed to type for analysis.

Descriptions of the Pictures and Projective Responses Related by Patient:

In this report the results will be reviewed in terms of those, which were considered to be most immediately relevant for evaluating the patient’s ability to mentally process sexual imagery.

Urogenital Card (VIII):

It may be observed that this picture present visual input which facilitates the evaluation of the male patient’s propensity to permit phallic material to register in consciousness.  Although statistical parameters are not yet available, our research group with this anatomical picture series has compiled extensive clinical experience.  It has been found that with this picture virtually all patients[2] perceive anatomical content in viewing it.  A common response involves first responding to the upper configuration as “kidneys” and then perceiving the lower areas as “bladder and penis.”

Remarkably enough, the patient when shown this picture simply responded – “It looks like a couple of potato sacks.”  Judging from his non-verbal behavior in inspecting the anatomical ‘ink-blot,’ the observer considered that this non-anatomical response represented the only imagery that registered in consciousness.  However, it must be acknowledged that it is, of course, impossible to exclude the possibility that the patient saw the sexual content, but elected to not report it.

Under the drug-induced hypnotic state the patient responded as follows:

“That looks like a couple of men … a couple of men’s heads … there’s an eye (black mark on left kidney shaped object) … they’ve got no hair … and this is their noses down here … I don’t know what that thing could be (lower area depicting bladder and penis) ... it looks like another person off in the distance because it is smaller than these two … another person’s head with something on his head … and these two guys are standing here talking … they could easily be a couple of potatoes or a couple of people … (patient inverts card) … it still looks like two potatoes regardless of the way you hold it.”

It may be observed that the relationship between the pictorial reality (i.e., urogenital system) and the patient’s response pattern to this picture was highly remote.  It is suggested that the patient’s imagery was much more dreamlike because the drug had released psychological inhibitions.

Judging from the patient’s response, it may be inferred that the picture’s connotations more strongly impinged upon consciousness than in the non-drug state.  Thus, the imagery was stated to resemble the facial area of “a couple of men.”  However, this interpretation is complicated by the fact that previous research has shown that under barbiturate sedation, body consciousness tends to focus on the head (Cassell and Hemingway, 1970).  Consequently, it must be recognized that a partial determinant of his response could have been a drug-induced artifact.

Next, one might consider the analogy between the projective response to the lower area – which depicts, in a covert fashion, the bladder and penis – as “a man with a mask over his eyes,” and his apparent failure to “see” what is represented in that aspect of the picture.  It is suggested that at some level of consciousness there was psychic awareness that the visual input provoked anxiety.  In this sense the “mask” may be interpreted to symbolize the patient’s reluctance to “see” the phallic imagery impinging upon consciousness. Lastly, attention might be directed to the response “candlestick with a light burning at the top.”  It is of interest that when the therapist later asked the patient to associate to this word he responded as follows:  “light bulb … darkness … stars … moon … lamp … funny shaped lamp like Aladdin’s lamp.”  It is tempting to interpret the fact that you rub the later object in order to obtain magical effects, as symbolically reflecting the patient’s masturbation fantasies and unresolved sexual tensions.

The last part of the response sequence indicates the re-emergence of non-anatomical content in awareness.  Again, it appears as though the patient failed to consciously recognize the phallic material inherent in the picture.

After showing all the pictures to the patient in the drug situation, certain cards were presented for a third time.  The Urogenital Card was the first of these.  This phase of the case study was designed to have the therapist work with the patient until the phallic material inherent in the picture registered in consciousness.  The patient’s anxiety in this situation was constantly evaluated and maintained within a range ordinarily employed in desensitization behavior therapy techniques.

When this card was presented to the patient, the therapist introduced the anatomical content at a higher level of awareness with the following comment:  “You said that this picture has to do with “potato sacks” or “men.”  Now, let’s suppose that it has to do with body:  What do you see?”  With this suggestion, the patient’s anxiety level increased and he became noticeably perplexed.  After a long pause during which the phallic content more strongly impinged upon consciousness, he then asked the question “male or female?”  He was then informed that it was whatever he saw in the picture.  After another lengthy pause, during which he appeared to become even more anxious, the patient reported, “that looks like a man’s penis … and that looks like his testicles … and that’s all that I can see.”

This deviated from previously observed responses in our research unit.  Instead of initially referring to the upper areas as “kidneys,” and then subsequently perceiving the other areas in the male urogenital system, he first responded to the lower areas as “penis.”  However, more unusual is his response “testicles.”  Thus he substituted more anxiety laden somatic images in consciousness over anatomical content more clearly depicted in the picture.

In a retest examination, six months later, he responded as follows:

“It looks like two red things … like potatoes … it could be the shape of a person’s head … the black spot looks like an eye … the colored part hanging down looks like a stem or foot joining these together.”

After having previously perceived the sexual material inherent in this picture, it is remarkable that six months later he once again failed to report seeing anatomy.  Eventually, he was reminded of the anatomical content.  In this instance, he projected the following pathological anatomy response:

“It’s a man’s penis but it has a funny shape the way it hangs down … it is swollen and there is a big lump on it … it doesn’t hang straight down … it looks like the after effects of sexual intercourse … it’s aching and has syphilis or something … the testicles look swollen too.”

This may be interpreted to represent a direct projection of his hypochondriacal concerns about the effects of sexual intercourse.

Male figure card (X):

This picture clearly depicts the outline of a man’s body.  It permits the patient to project responses related to the hands, the feet, the pelvic area, the limbs, the ribs, and the lungs.  Initially, in viewing this picture the patient appeared to be markedly inhibited in that he only reported the following:  “It resembles the shape of a man … but he doesn’t have a head.”  Since ordinarily male subjects do not comment on the missing head, this aspect of the response seemed worthy of note.  It may be postulated to reflect an upward displacement of his concern about losing his penis.

Under sedation, he responded as follows:

“This looks like the shape of man … two arms … and that’s his neck … and he’s still got no head.  That’s his two legs … and that could be his ribs … it looks as though somebody’s holding his hand around him because I see three fingers.  And this thing … well, that looks like two potato sacks … joined together and tied at the top. They’re narrow at the top and they’re wide at the bottom … they’re tied together.  That’s an owl or something (referring to the pelvic area) an owl or ah … bird … or a bat, something like that … with … with wings anyway.  These little pointed things look … they’re … horns on an owl … a horn owl.”

Once again it is evident that the sedative-induced hypnotic state was characterized by richer flow of visual images and verbal output.  In the opening phase of the response sequence there is further evidence of the patient’s concern over the figure’s “missing head.”  Next, it may be observed that the imagery stimulated by the rib-like structures in the picture had a bizarre and threatening connotation, in that “somebody’s holding his hand around” the man in the picture.  Remarkably enough, the areas, which are ordinarily stated to represent “lungs”, are seen as “potato sacks.”  Thus to complicate interpretation, there is evidence not just of perceptual inhibition of phallic imagery but other organ images as well.

Lastly attention might be directed to his response to the pelvic area in the figure.  Since the symbolism is most interested, the interview will be reported in detail.

Therapist (T): “Suppose that it all had to do with one man.  What do you see now?”

P:         “Well, that could be a belt buckle on his pants or anything.”

T:         “What else could it be?”

P:         (long pause)  “I don’t know … can’t think of anything else.”

T:         “You seem to think of that an awful lot.  What is that?”

P:         “I don’t know.  I can’t figure out what it could possibly be … what part of a man that represented … (patient shifts focus of attention from the pelvic area to the lungs) … this looks like the insides … but … that there … I can’t figure out what that could be … can’t figure out why the insides would be that low down … it’s down below his waist or something … it just doesn’t seem as though it’s not normal because he is something different than other men … something that’s there and is not supposed to be there and that’s why I can’t figure out what it is.”

T:         “If it’s below his waist what is it likely to be?”

P:         “Well, it could be his belly but I guess it’s kind of big.”

T:         “Anything else it could be?”

P:         “No … I’m afraid I can’t.”

In this aspect of the interview the patient finally correctly identified the red areas as “internal tissue” – although he never labeled them as “lungs.”  However, at no time did the imagery relate to the male genitalia stimulated by viewing the pelvic area of the figure register in consciousness.  Yet, it is suggested that it strongly impinged upon awareness in that he projected concern about his own sexual organs as indicated by the response “it’s not normal, etc.”

This picture was represented to the patient for a third time after his seeing phallic material in the Urogenital Card had influenced the patient’s perceptual set.  The dialogue between the patient and therapist follows:

T:         “Is there anything different that you see in this one now?”

P:         “No, I can still see the body of a man.”

T:         “Which body part would be represented here?” (Pointing to the pelvic area)

P:         “Well, it’s that part of the man … in that shape I cannot say what it could be.”

T:         “What kind of shape would it looks better?”

P:         (Pause with no response).

T:         “Suppose that it was the shape of a candlestick, what would that make you think of?”

P:         “Well, there are a number of things that I could name off for a candlestick” (pause).

T:         “Suppose I told you that the part here is the same as in this picture (pointing to the Urogenital Card) in representation, what would you think of it?”

P:         “this sure looks like a man … he’s going to the bathroom or something … that looks like a penis” (patient’s anxiety high).

T:         “You seemed to have a lot of difficulty thinking that this is a penis.  The other thing that you said was that the guy had something wrong with him” … “Is that what you think about yourself?”

P:         “Yes, that’s right.”

T:         “There’s nothing wrong with you.”

P:         “I still think that I do … I don’t know why.”

This aspect of the interview shows how this research technique may be used to stimulate somatic imagery more in the context of a relationship having potentially therapeutic, as well as diagnostic implications.  Under sedation, in this situation phallic imagery was activated in the patient’s unconsciousness. There was a great deal of resistance in bringing this into full awareness and considerable concomitant anxiety. However, in the state of relaxation induced by the drug, the therapist was able to interpret to the patient his psychopathologic body attitudes and partially desensitize the focal somatic anxiety.  Of course, it is difficult to estimate the relative effects of visual input from the picture as opposed to verbal cues from the interviewer – in finally introducing the phallic imagery into conscious awareness.

Six months later, in a retest situation, he responded as follows:

“That looks like the outline of a man … there are two arms and two legs and a neck … there is no head though … the red part … I don’t know … could be the intestines or some part of the body such as the heart or something.” This response again avoids reference to the phallic aspects of the figure.  It is also of interest in that the patient readily recognized the anatomical implications of the internal lung-like structures.  However, this visual input was not processed in a normative fashion as “lungs” but consistent with his regression to an oral theme perceived as “intestines.”

Human figures card (III):

This picture presents line configurations, which may be seen to represent human figures.  The bodies are in close proximity and share the same “body buffer zone” (Horowitz et. al., 1964).  Ordinarily, they are seen as a man (left) and a woman (right) interacting in some way such as dancing.  The red areas represent “hearts” which are often stated to symbolize their “love.”  Normally a few subjects give non-anatomical responses such as “lights” or “red balls.”

The patient’s initial response was unremarkable in that he saw the picture as representing “a couple of go-go dancers” with the red depicting “apples.”  However, under drug conditions much more clinically relevant material merged.  He responded as follows:

“That looks like a couple of go-go dancers or something … this guy (left) looks as though he has a knife in his hand and she has got something too but I don’t know what it is … it looks to me as though they are going to cut those things in half … they are some kind of food or something … maybe that’s his hand hanging out there … they found a couple of apples … he’s going to cut one in half and give her one and himself one.”

The fact that the patient perceived the male dancer as having a knife in his hand suggests that the theme represents a direct projection of castration anxiety and/or hostility toward women.  There is also evidence of regression to an oral rather than sexual level of interaction.  It also might be noted that when the patient’s therapist heard this response, the following question was asked.  “What does cutting an apple in half and giving it to her make you think of?”  Interestingly enough, in responding, the patient identified with the picture in a regressive fashion stating, “Well, he likes her … I used to do that when I was a boy.”

In the retest situation six months later, his response was quite different:

“There are two people … two pairs of legs and an arm … the red dots could be apples.”

When asked the sex of the figures, he reported that they were two “men.”  Further, each of the two parts in between reminded him of a “penis.”  The one on the left man was seen to be “long and erect” and the right one as “short and soft.”  When asked what they were doing, he stated they were “standing there comparing sizes.”

In interpreting this response, it is pertinent to note that in the interim since originally tested, the patient had for the first time in his life become involved on one occasion in exhibitionistic behavior and genital manipulation with a known homosexual.  It is evident that the imagery stimulated in consciousness by this picture is much in line with this deviant behavior.

Female figure card (VII):

This picture was designed to evaluate the extent to which the female patient assimilates the feminine aspects of her body image into a gestalt.  For the male patient, it appraises his ability to recognize and mentally process sexually evocative material related to a woman’s body.

It presents two main aspects.  The one of primary significance concerns the humanoid lower configuration consisting of two lines depicting the outline of the body, the hand and feet.  There is a red area between these included to elicit responses related to the stomach or genitalia.  The upper red area denotes the mouth, and the black, the hair, or if the picture is seen as a man, a moustache.  The second aspects refer to the top red object.  It presents additional anatomical material relating either to the head area or the heart.  Ordinarily, this picture was stated to represent “a dancing woman” with the upper object being “an apple.”  Thus the mature response involves assimilating the two lines which are separated in terms of the right – left axis of the body into a gestalt, and then assigning feminine sexual identification to the figure.

In viewing this picture, the patient responded to the upper configuration in the normal fashion seeing it as “an apple.”  However, consistent with his past history of aversion to women he simply saw the lower lines as representing “two animals.”  The black area was stated to represent “a little black seal.”  His failure to resolve the line configurations into a gestalt representing the body of a woman provided further evidence of his anxiety in mentally processing sexual imagery.  The perceptual defense utilized in this instance, involved a breakdown of gestalt mechanisms of perception.

The patient’s response sequence in the retest situation is of considerable interest because it shows how the separate components are eventually resolved into a gestalt as the patient’s anxiety is controlled.  His associations to the picture follow:

“This is a fish or an apple or bell or something (top red object) … and it’s a big fish and he’s swimming after … these are a couple of snakes (lower lines) … this looks like a fish or something here swimming … this (pelvic area) could be a dead bird lying down or a lake … (long pause) … it’s something shaped like a person’s body … to legs and that looks like a guy’s moustache above the mouth (black area).”

The interviewer then stated:  “You said before that looked like a little black seal.” The patient then continued as follows:

“Like that’s something else in my head that I never thought of before … it looks like a man’s moustache … this is an apple on the tree and it looks as though he is reaching for it.”

Finally, the therapist asked him, “is it a man or woman?”  He then responded as follows:

“Well, it’s a woman I’d say … looks as though she’s got lipstick on or something and that’s why I think it is a woman.”

In the opening phrases of his response the patient clearly substituted non-anatomical symbolic content for the structure depicting the body.  Particularly noteworthy in regard to his past feelings of sexual inadequacy, is the response “dead bird lying down.”  Next, attention might be directed to the fact that when the human figure finally succeeded in registering in consciousness, it was assigned a masculine connotation.  This is remarkable since the picture is suggestive of the female rather than the male body.

This avoidance of the feminine imagery is consistent with his past behavior in relation to women.  Finally, he was eventually able to connect this distortion in perception.  However, six months later, he saw it as the figure of a man.

Heart genitalia card (VI):

This picture presents anatomical content relative to the heart.  More strongly embedded in the figure are cues relative to union of the male and female genitalia.

The patient initially responded as follows: “This is an animal standing inside a red object which could be a cloud.”  Under drug conditions, he stated:

“That could be a giraffe with those things sticking out of its head … they could be horns (central object) … and it looks as though he sees something coming and is standing on the other side of a bush or something … he’s standing in a bush … this is a bush (red area) … and this red thing here I don’t know what it is … I think that it could be a mop of hair hanging down but giraffes don’t have hair so I don’t know what it could be.”

Again the patient substituted non-anatomical imagery when his consciousness was stimulated with material resembling the body.  However, at the termination of the drug session when informed that the picture had anatomical content, he then stated that it looked like the “vagina.”  In this situation the organ image of the more anxiety-laden female genitalia, rather than the cardiac aspects of the configuration succeeded in registering in consciousness.  It is suggested that, at this time in the study, he had been partially desensitized to mentally processing sexual imagery.

In the retest situation, six months later, he initially failed to detect the anatomical content but when reminded of it reported once again seeing a “vagina.”  When it was further suggested to him that some people see the central object as a “penis,” he became markedly anxious refusing to accept this possibility.  In other words, when confronted with imagery depicting union of male and female genitalia, he totally blocked this from consciousness.

Body gestalt Card (II):

This picture evaluates an individual’s ability to organize separate components of the body into an overall image in the form of a gestalt (e.g., “A person with a big smile”).  It consists of three separate units arranged in such a fashion to depict the human form.  The top part was created to elicit projective responses related to the head.  The middle part depicts the oral region, but is sufficiently ambiguous in outline to present suggestive imagery relative to the heart.  The lower black area represents the arm, body and legs.

Initially, the patient responded only to the latter seeing it as “a person with his hands up in the air.”  This failure to respond to the other aspects of the figure suggests that the patient had somatic anxiety in the regions depicted (e.g., “mouth,” “heart”).

Under the drug state, he responded as follows:

“There is a person … the top part is an animal … its got two heads and it only has one leg … this looks like a person in a drawing and this is his body and this is his leg … and this is somebody’s mouth.”

It is apparent that in the retest situation, he fails to resolve the separate components of the image into a gestalt.  Moreover, his response to the upper black area as depicting an animal with two heads and only one leg is highly unusual.  The missing leg in the response may be interpreted to reflect his own undue “castration anxiety.”  Also, it is noteworthy that the drug released inhibitions to the extent that he could see the “mouth,” although interestingly enough, it was considered to be separate from the rest of the picture.  It might be noticed that a pattern is forming, whereby the exhibitionist failed to recognize anatomical structure in the pictures.  The other feature involves themes related to the oral region.

Finally, for comparison purposes, an outline will be given of his responses to two anatomical pictures, which lack direct sexual referents.

Chest Cavity Card (IX):

This picture illustrates the rib cage and heart to a very high degree and is invariably so recognized by most subjects.  Yet this patient saw this as “two people eating” failing to recognize the anatomical content which is so strongly present in the picture.  Under drug conditions, he stated this looks like:

“the shape of a person’s head … that’s the girl’s hair hanging down … but the it could look like … oh, it reminds me of a couple of seahorses or something … and this is their tails … that’s their bodies and that’s their heads … and they are eating some kind of food or something … don’t know what it is … that’s the rippling of the water … oh, these are seahorses.”

This card illustrates how the patient inhibited not just phallic material but other somatic imagery as well.

Discussion:

A projective technique employing a series of newly designed anatomical pictures has been developed to stimulate somatic imagery.  This approach has been illustrated in a patient with exhibitionism.  Marked resistance was observed in bringing sexual images into full registration in consciousness.  This finding may be appraised in the context of existing theory partially derived from more traditional psychoanalytic procedures (Fenichel, 1945).  The extreme perceptual inhibition of the phallic imagery observed in the present study has certain theoretical implications.  There is a definite parallel between this and the view that in exhibitionism the individual unconsciously says to his audience:  “Reassure me that I have a penis by reacting to the site of it.”  The subjective feeling that his penis might disappear becomes highly plausible to the outsider if one considers the excessive repression of sexual imagery noted in the exhibitionist studied.  It is quite understandable how an observer’s response to the exposed penis could well provide a useful external source of reality testing for refuting this pathologic body fantasy.  It might be noted that this perceptual defense has also been observed in tachistoscopically exposed illustrations of human anatomy to

subjects with focal somatic anxiety secondary to psychophysiologic symptoms (Cassell, 1966).

A further existing theoretical formulation of exhibitionism is that the patient is choosing women as observers of the deviant behavior, in a magical sense, is unconsciously saying:  “I show you what I wish you would show me.”  This is considered to deny the apparent castration of the female’s body, reducing the fear that this might happen to him.  It may be recalled that the patient’s responses to Cards II, III and VII (retest) were consistent with what is implied in the psychoanalytic construct “castration anxiety.”  His phobic-like aversion to processing imagery related to the female body was observed with Cards VI and VII.

Attention might also be directed to the patient’s tendency to project oral rather than genital themes in viewing the pictures.  It’s consistent with the thesis that the exhibitionist is “an infantile individual” concerning his sexually deviant behavior (Karpman, 1948).  Along the same lines perhaps, it is pertinent to recall that Kinsey found that 20 percent of pre-adolescent boys who engage in sexual play have exhibitionism as the limit of the activity (Kinsey, 1948).  It is suggested that this regressive aspect has functional significance in that it avoids the anxiety stimulated by sexual imagery.

Another subject for discussion concerns the observation that – like the present patient – exhibitionists in general are sexually inhibited (Rickless, 1950).  In this context brief attention might be given to the psychophysiologic aspects of normal sexual functioning.  Sexual arousal in the “normal” male involves the interaction between a physiologically originating drive state and mental imagery relating both to his genitalia and evocative images pertaining to that of a woman.  For the exhibitionist under present study, it would appear that sexual tensions would have to be intense before the resultant union of male and female imagery would register in consciousness and motivate normal heterosexual behavior.  It is suggested that abortive attempts to discharge these occurred when the patient acted out sexually in a state of excitation by impulsively exposing his genitalia.  As was evident in the retest situation, exhibitionistic behavior of a homosexual nature was also attempted by the patient in order to provide a release for his sexual impulses.

Of course, as might be expected with the introduction of a new technique, all the results do not fit the previous theoretical frame of reference.  The above formulation may be seriously challenged since the patient was remarkably insensitive to detecting all anatomical content in the pictures – sexual or otherwise.  Thus, there was evidence of perceptual inhibition of images depicting the lungs, mouth and heart.  While it may be contended that the oral region and the heart provide imagery during the states of sexual arousal (Schneider, 1956, 1957), it might appear that the data do not strongly support a specific defect in the patient’s perception of the genitalia.  However, since the patient did not have psychosomatic symptoms in other regions of the body schema this thesis warrants consideration.  Moreover, in the course of therapy, he was found to be made more anxious by the discussion of sexual themes – rather than those relating to other aspects of the body.  Therefore, in all likelihood, it would appear that the primary disorder involved aversion to the genitalia, which secondarily spread to involve other somatic regions.

The patient’s avoidance of female anatomy in the pictures brings to mind mechanisms operating in phobic disorders (Snaith, 1968).  While the two conditions differ in that the exhibitionist also avoids material presumably related to his own body rather than an external object, the comparison has heuristic value.  Further, it has certain theoretical implications in terms of therapy.  For example, it is tempting to consider that just as certain clinicians may treat phobic disorders through desensitization procedures, the same general principles might be applied in reducing anxiety related to conjuring up in consciousness scenes involving union of male and female genital imagery.  Indeed, the manner in which the therapist assisted the patient in mentally processing sexual images under narcotic relaxation employed insights borrowed from both behavioral and gestalt therapy procedures (Perls et al, 1951).  However, to be sure, it did not seem to have much “lasting” effect since repression still occurred in the six-month follow-up session.

Stimulus Plate SIT-20: Vertebral Skeleton / Unmasking Skeletal Reality

Every night humans spend several hours in the mysterious inner world of our dreams. It has been estimated that at any time almost half of the world’s population is asleep dreaming. Those with an innate sense of curiosity have long been fascinated with the meaning of the images and affect experienced during the thousands of hours spent in this altered state of consciousness.

This project explores symbolism in a devil dream. A severely depressed adolescent girl (T) reported it. She had been hospitalized after experiencing suicidal and homicidal ideation. She was interviewed using the Rorschach and SIS stimuli as sources for visual stimulation of daytime imagery. It will be shown how the analyzing the content and emotional linkage of the projected responses provided information for analysis and interpretation.

For a few illustrative moments, please leave your immediate time and space reality coordinates behind and imagines entering her inner world of dreams:

“ I had a dream that me and my brother were having fun and were laughing and having fun as we usually do and then all of a sudden, something swished by me like someone was running real fast by me but with no foot -- but no foot -- but no running sounds and then all of a sudden, something by  -- appeared in front of us and the lights were turned out -- all the lights went out and this bright thing was in front of us and then it turned out to be Lucifer and he was saying that we were a mistake to this earth, that we were going to ruin his plans and then he threw my brother up against the wall and he made his arms spread out and his legs together. He made a slash mark from elbow to elbow and then from forehead to waist like a cross and he let him bleed and he said I will do anything just to get rid of you guys. I am over -- I am overpowered and he -- and I shall take over and then he killed him by -- he killed my brother by sending a hole through his forehead all the way to the back and then I remember turning away and just running and there was such long darkness and then I had this feeling of being frightened like I knew something was behind me and not knowing what to do and not knowing what would happen next and all of a sudden something hit me on my back and then I died and I heard this cruel laughter in the background and then I woke up. Discussion between Therapist (Dr. B) and Patient (T) follows:

The Dream’s Affect and Symbolism:

Dr. B.: How were you feeling throughout this dream?

Dr. B.: It was good.

T.: Yeah. Yeah.

Dr. B.: Okay. And then what happened?

Dr. B.: You love him a lot.

T.: Yeah, and I felt frightened, like -- and I felt lost.

Dr. B.: Okay. And what's the dream all about? Remember we talked about it a little bit?

Dr. B.: What's that part all about do you suppose?

T.: I don't know. I've been thinking about it for a while and I also thought about it yesterday after gym group.

Dr. B.: What thoughts have you had about a...

Dr. B.: Please try to remember your thoughts.

T.: What I thought was I was confused and not really sure.

Dr. B.: What did you think about what the kids in the dream analysis group said about the dream?

T.: I think I got some really good feedback about my dreams.

Dr. B.: Tell me about the feedback. What was good about it?

T.: Like some people gave me thoughts of what they thought my dream was about and.....

Dr. B.: What were those thoughts, do you remember?

Dr. B.: Remember the one girl wondered about you and if you felt part of you had Satan?

T.: Oh, yes.

Dr. B.: Tell us about that.

Dr. B.: She said that?

T.: Yeah.

Dr. B.: How did you feel when she said that?

Dr. B.: Uh-huh (affirmative).

T.: And that something did get hold of me (She readily accepted the concept of having a devilish part to herself) but then I also felt hurt because -- for my mother to say that about me.

Dr. B.: What way did that hurt you?

T.: It felt like I wasn't a good enough daughter for her. (Her self-esteem was reduced thereby setting the stage for severe depression) and that I couldn't get a second chance.

Dr. B.: Do you sense there are a good part and then a bad part within you?

T.: Yes.

Dr. B.: What's the good part?

T.: The good part is always closeted and always willing to learn and knowing what to do.

Dr. B.: And helpful to others (She frequently gave emotional support to her brother and hospital peers.)

T.: Yeah.

Dr. B.: And the bad?

T.: The bad or having thoughts, the wanting to hurt myself or to.....

Dr. B.: Tell us about those thoughts.

T.: I was pretty upset with myself because I let some things get over or carried away and I just felt like I had to punish myself.

Dr. B.: What else besides hurting yourself the bad side represents?

T.: Of wanting to rebel and just do what I want and having thoughts of like just things and meaningful words to other people and actually having some thoughts of wanting to hurt people.

Dr. B.: What was your conflict like with your mother?

Dr. B.: Both.

T.: My conflict with my mom was -- when I assaulted her was I felt like she was provoking me and so I just finally gave in.

Dr. B.: What way was she provoking you?

T.: Like she was laughing at me (Like the devil in her dream.) and saying go ahead and do something so I can call the police, you just wait and see and laughing at me (At age eleven during her first hospitalization, she had learned in therapy not to entirely blame herself for her mother’s abusive behavior. Consequently, she was less guilty and her self-esteem was greater. However, she still could be provoked into rage and assault by her mother’s provocative psychological abuse. By contrast, she was never out of control in school or other settings).

Dr. B.: It hurt.

T.: Yeah.

Dr. B.: Yeah. Okay. Anything more you want to say about your dream? Oh...

T.: No.

Rorschach Symbolic Content Analysis:

For this interview methodology, it was hypothesized that projective responses are generated from the same stream of consciousness as the imagery in nighttime dreams. Initially, she was asked to report what she saw (i.e. Real of symbolic content) and felt (i.e. Affect associated with the image) in relation to viewing the ten Rorschach cards.

Historically, Herman Rorschach as a visual basis for structured clinical interviewing originally created these. Consistent with these historical roots, the following viewing procedure was done. Initially, the cards were presented in the traditional order using them for a visual source for obtaining free association responses.

In the follow-up detailed enquiry a different order was employed for interviewing. All ten plates were placed on a table face up. She was then asked to indicate the three that she “liked the most” and the three that she “liked the least”. This emotional rating procedure gives more priority to the underlying image’s affect linkage than the content. Extensive projective work indicates that in clinical populations, this approach has more value than simply obtaining projective responses on simply the order decided upon by either Rorschach or the original publisher. It facilitates establishing a subjectively determined hierarchy of positive and negative emotional feelings in assessing the significance of what is seen, or avoided. When follow-up content analysis is employed the clinician has a powerful emotionally driven technique for exploring the overt, as well as the symbolic meaning of responses.

The following represents a transcription of the Rorschach structured interview:

Dr. B.: Okay. I am going to show you some of these cards today. Have you seen these before?

T.: Yes (She had previously been tested by a psychologist six months earlier employing traditional administration and scoring techniques. In a later section of this article, the result of testing will be reported).

Dr. B.: Okay. This is the first card, what do you see?

T.: I see two animals that have wings with their feet together like they're climbing up.

Dr. B.: Okay. Do you experience any emotions with it?

Dr. B.: What are they?

T.: No feelings or emotions about it (See later).

Dr. B.: Okay. We'll put this over here and then your - the second one?

T.: It looks like two people squatting down and having their hands together like they're in prayer.

Dr. B.: Any feelings?

T.: It makes me feel good because about the prayer part, like they're praying.

Dr. B.: Do you pray much?

T.: Yes.

Dr. B.: Tell us about that.

Dr. B.: And what's your view of God as compared to the devil now?

Dr. B.: Do you ever pray in your dreams?

Dr. B.: That's a form of prayer, isn't it? And one would just say that in a dream?

Dr. B.: Do you have many dreams of those?

T.: I haven't had many but it -- I do get them (She did not always symbolically disguise her identify in some of her self destructive dreams).

Dr. B.: Yeah. Okay. Here's the third one.

T.: These little parts look like monkeys in - upside down and looks like two people holding something.

Dr. B.: Any idea what?

T.: Like something to hold water in like a jug.

Dr. B.: Okay. Thank you. And then this one is number four.

T.: It looks like a dragon...and then these two parts right here look like shoes.

Dr. B.: Any feelings with that?

T.: No.

Dr. B.: Okay. Here is the next (V)

T.: This one looks like a bat.

T.: And this part looks like an animal face -- these parts, like I figure it's an animal but they eat ants.

Dr. B.: Okay 6A?

T.: Looks like two men back to back like they're about yeah, like they're ready to do something.

Dr. B.: Like what?

T.: Like -- what's that called? Like where you both … where they both step up 10 feet, not seeing each other and they turn around.

Dr. B.: A duel?

Dr. B.: Okay. 7A?

T.: Looks like two ladies dancing.

Dr. B.: Any feelings there?

T.: Fun.

Dr. B.: Eight.

T.: Looks like two bears are climbing up a mountain.

Dr. B.: Any feelings?

T.: T.: Just peacefulness.

Dr. B.: Mm-hmm (affirmative) Nine?

T.: Well, this orange part looks like they're two mooses and then this is -- the green part looks like there are two people there holding something.

Dr. B.: Like what?

Dr. B.: Uh-huh and how do you feel looking at that?

T.: Good. I like babies.

Dr. B.: Last one?

T.: These parts right here look like they're two more men.

Dr. B.: That's the sort of orange parts on the side?

T.: Yeah, with the yellow and the.....

Dr. B.: On the lower left.

T.: Yes.....

Dr. B.: Yeah, and the right. What do they look like?

T.: Two women like the yellow part's their hair and their heads are thrown back. Looks like they're spilling something, or it looks like a blanket.

Dr. B.: Any feelings?

T.: It looks like -- to me it looks like -- something like a Native culture (Her mother’s background).

Dr. B.: Okay. Thank you. Now, we've got them all -- arranged here (Plates placed in order on interview desk face up). Can you pick out the three you like most?

T.: I like that one (Card II).

Dr. B.: What do you like about that?

Dr. B.: Okay. What is the second one that you like most?

T.: That one (Card VII).

Dr. B.: What do you like about it?

Dr. B.: Right - And the third one?

T.: That (Pointing to Card III).

Dr. B.: And what about this one?

T.: Because it looks like people and they're doing every-day like things.

Dr. B.: Okay. Now tell me the three you like least, the ones that -- any one that would bother you or what's - what bothers you most in that?

T.: This one because it looks like a bat and I don't like bats (Card V).

Dr. B.: What is there about bats that bother you?

T.: Like I don't know, it's something about them that I don't like.

Dr. B.: Like what?

Dr. B.: Okay. And the second one that bothers you most?

Dr. B.: What bothers you about that?

T.: Because it's a dragon (A threatening mythical creature symbolically denoting her abusive mother).

Dr. B.: A dragon? And what does the dragon bring to mind?

T.: Hurtful things.

Dr. B.: Like what?

T.: Like -- I don't know, it looks evil.

Dr. B.: In what way?

T.: Like it's just out there to get you.

Dr. B.: Okay. And then the third one that bothers you?

Dr. B.: And what is there to fear?

T.: Because it also looks like an evil face, like it's laughing at me.

Dr. B.: What does that remind you of?

Dr. B.: Uh-huh that isn't fun when she provokes you, is it? How do you feel?

Transcription of SIS-I Structured Interview:

Dr. B.: No. Okay. I'm going to have this -- put these away. Now we're going to look at the SIS Cards Here's your first card. What do you see there?

T.: I see a lot of things… the red parts look like two birds.

Dr. B.: Uh-huh

T.: And then it looks like two people. They're both ladies.

Dr. B.: Uh-huh

T.: And looks like they're dancing.

Dr. B.: And how does it make you feel?

Dr. B.: Yeah. Okay. Now what do you see in the second one?

T.: That part looks like a heart. And this part looks like a man's head And then a whole -- like his chest -- head.

Dr. B.: That's the top part. Any feelings?

T.: Heck no.

Dr. B.: Okay. The third?

T.: Looks like a man and a woman. Looks like they're talking.

Dr. B.: Any idea about what?

T.: Wait, no, doesn't look like talking, looks like they're playing a game if that was.....

Dr. B.: Any feelings?

T.: Fun.

Dr. B.: Number four.

T.: That top part looks like an apple and the other part looks like a lady … looks like she's like just blackened somewhere.

Dr. B.: Any feelings?

T.: No.

Dr. B.: Okay. Five?

T.: Looks like a turtle… and the left part -- looks like parts -- looks like a man's head -- his head and there's his neck and chest.

Dr. B.: Six?

T.: Looks like two seals and that part in the middle looks like a person, stick figure and then on a heart.

Dr. B.: Any feelings?

T.: Reminds me of Valentine's Day.

Dr. B.: Yeah. Well, it's not too long since Valentine's, is it?

T.: Nope.

Dr. B.: Did you have fun?

T.: Mm-hmm (affirmative).

Dr. B.: Good for you. Number seven?

Dr. B.: Mm-hmm (affirmative).

T.: It seems like it's a sign between evil and good (This “sign” directly symbolizes her own personality splitting and personality tendencies to dissociate).

Dr. B.: Uh-huh (affirmative).

T.: Yes.

Dr. B.: What part's evil, what part's good?

T.: It's the dragon's evil and the heart's good.

Dr. B.: Okay any feelings apart from that?

T.: No feelings.

Dr. B.: Okay. Thank you. Here come eight.

T.: It looks like a rib cage. This is a person's body and this is like the heart.

Dr. B.: Uh-huh any feelings?

T.: I'm going to say the hospital where they like take X-rays.

Dr. B.: Yeah. Here is Card 9.

T.: It reminds me of you know those ultrasounds where they put that down at the belly.

Dr. B.: Right.

T.: That looks like twins -- babies in there…Every time I see a baby, it’s something like someone coming onto me. It makes me feel good.

Dr. B.: How about Card 10?

T.: Looks like a piece of meat, like from a cow or something.

Dr. B.: Any feelings?

T.: I don't like it when people kill cows or animals for their meat. That makes me real angry.

Dr. B.: Card 11?

T.: Looks like a snake.

Dr. B.: And how do you feel looking at that?

T.: Fear because I don't like snakes.

Dr. B.: What don't you like about them?

T.: They can bite you (Her concerns about being bitten here and in the “Bat” Rorschach response represent projections about her injuries from both her mother and her own self mutilating behaviors.

Dr. B.: Okay. Card 12.

T.: Like a dragon. Like a dragon but a good one (Here the mythic symbol denotes her “good” side. This illustrates how the immediate emotional linkage to an image can provide clues as to the symbolism).

Dr. B.: How do you feel looking at it?

T.: Happy.

Dr. B.: Card 13.

T.: It reminds of a heart...going bad emotionally (Upside down).

Dr. B.: And -- okay. You turn it upside down and it reminds you of a heart going bad and what does it bring to mind?

T.: Like a person that's heartless like hateful. Looks like something took control of it.

Dr. B.: Does that remind you of any of your own issues?

T.: Yeah.

Dr. B.: Right. What?

T.: My internal depression because -- when I am injured or depressed. It's like I become heartless, like I don't care.

Dr. B.: And you want to hurt yourself?

T.: Yeah, or others.

Dr. B.: What way do you want to hurt yourself and what way do you want to hurt others?

T.: On myself, I would hurt myself physically and others I'm going to hurt them mentally.

Dr. B.: And do you know why you want to hurt yourself physically?

T.: Because of all the mistakes I've made in life.

Dr. B.: When you cause physical pain, how does it affect you emotionally?

Dr. B.: And when you hurt others, how do you hurt others?

T.: I like to make them do everything to me, I'm happy and so I hurt them emotionally.

Dr. B.: By doing what or.....

T.: Giving them the treatment that they give me like a taste of their own medicine or calling them names.

Dr. B.: Do you ever hurt people that have never done anything to you?

T.: No.

Dr. B.: No? Okay. Card 14.

T.: I would say about an animal's head like it's getting a cat scan or rainbows and makes me feel good because like they're trying to find out about animals and they're helping the animal.

Dr. B.: You like animals.

T.: I love them.

Dr. B.: Yeah Number Fifteen?

T.: Looks like a crocodile.

Dr. B.: And how do you feel looking at it?

T.: Fearful because I don't like crocodiles.

Dr. B.: Because?

T.: Because they can kill people (Another highly threatening projection.

Dr. B.: Okay card 16?

T.: Looks like two ostriches heads.

Dr. B.: And how do you feel?

T.: Nothing.

Dr. B.: Okay. We're getting near the end. Card 17?

T.: It looks like a heart with a knife going through it (Clinical experience indicates that the “Knife in the heart” symbolism can represent extreme hatred and/or homicidal impulses).

Dr. B.: And how does that make you feel and what does that bring to mind?

T.: It brings to mind of hate.

Dr. B.: And when you think of hate, what comes to mind?

T.: A person that doesn't care about how other people feel just does what they want.

Dr. B.: Do you ever feel hate towards your mother?

T.: Yes.

Dr. B.: In what way? And towards yourself?

T.: In a way that it feels like she doesn't care for me.

Dr. B.: What way see yourself?

T.: That I'm a burden to others.

Dr. B.: Number Card 18?

T.: Looks like two angels.

Dr. B.: Two what?

T.: Angels.

Dr. B.: Uh-huh (affirmative). And how does that make you feel?

T.: Peaceful.

Dr. B.: When you think of angels, what come to mind?

T.: Guardian angels that help you.....

Dr. B.: Do you think of your -- do you have a guardian angel?

T.: Mm-hmm (affirmative).

Dr. B.: Tell me about her or him.

T.: She's always near me. She's with me right now. She's with me right at the door and.....

Dr. B.: And you feel more secure?

Dr. B.: Good then. Are your angels ever in your dreams?

T.: No.

Dr. B.: Okay. Card 19?

T.: Looks like two birds – gooses and they're carrying babies on their necks.

Dr. B.: Okay. And how do you feel looking at that?

Dr. B.: Right. The last one Card 20?

T.: Looks like two swordfish.

Dr. B.: Two what?

T.: Swordfish.

Dr. B.: Uh-huh (affirmative). Okay. And how does that make you feel?

T.: Good because I like animals.

Dr. B.: Mm-hmm (affirmative). Okay. Can you tell me the three that you like most?

(She selected five, nine and eighteen.)

Dr. B: Now tell me the three that you dislike starting with the one that you dislike most?

T.: This one (seventeen).

Dr. B.: What is there about that bothers you the most?

T.: It reminds me of hatefulness.

Dr. B.: Okay. And then the next one that bothers you the most?

T.: This one (seven).

Dr. B.: And what bothers you there?

T.: Reminds me of evilness.

Dr. B.: All right and one more.

T.: This one (thirteen).

Dr. B.: What does that remind you of?

T.: Evilness and hatefulness (Her memory storage is flooded with hateful imagery).

Dr. B.: Okay. This one (Presenting Plate I of the Rorschach again) reminds you of your mother's face sometimes?

T.: Yeah.

Dr. B.: And do you see your mother in your dreams much or her face?

T.: No.

Dr. B.: Does she appear in your dreams much?

Imagery Released by the SIS-II Video:

Dr. B.: This is like looking at what you saw in the video (Showing her the SIS Answer sheet). You indicated that you liked A16 the most and why was that?

Dr. B.: Nature can be healing, can't it?

T.: Yeah.

Dr. B.: And then B19, what did you see there?

T.: I said I'm trying to get hearts because it's -- one heart is broken.

Dr. B.: And what appealed to you about that?

of the projective response).

Dr. B.: In what way?

T.: That I'm trying to grasp for something that I -- that's broken inside of me.

Dr. B.: What way have you felt like your heart's broken?

T.: Like I have no hope and some stuff.

Dr. B.: You got lots of hope. I know when we feel down, we don't feel that way though but you do feel you have some hope now, don't you?

T.: Mm-hmm (affirmative).

Dr. B.: Good girl. And then B28, you liked that one. It's a nice one. It's one of my favorites. What do you see there?

T.: A girl holding a baby (She could not conjure up the normative response depicting a nurturing mother since she never had one. She could identify somewhat with the “girl” because she had nurtured her beloved brother).

Dr. B.: And why do you like that?

T.: I love babies.

Dr. B.: Next, let’s look at those that you liked least. The one that bothered you most was B29. You indicated that it reminded you of the devil (The dream symbol under projective examination!)

It may be of significance that it emerged in projective consciousness with the SIS-II Video. This projective procedure involves relaxation instructions, hypnotic floral photographs presented in a dreamlike moving manner. In addition the light in the video presentation can approximate the visual vividness of dream imagery.)

T.: Yeah.

Dr. B.: In what way?

T.: And it just seems odd because there's a man there and it's like he's going (The symbolic figure was seen as moving towards her in a threatening fashion - just like in the dream.) there is a shadow of his leg.

Dr. B.: Right. (In a demonic fashion, mother had repeatedly beaten her and her brother with objects such as a belt, a cooking spoon, and a coat hanger. She would find some minor excuse for the assault such as their not completing a domestic core. She would make them take down their pants and beat them on the bare buttocks. She reported that mother would sometimes smile, during the beatings, apparently enjoying the sadistic power.

She had witnessed many beating of her brother and felt great rage towards her mother as a result. The physical abuse stopped two years previously after her brother showed scars on his buttocks to a social worker. As a result, their mother was warned that she could have the children taken from her.

Dr. B.: In your dreams, does the devil -- what is -- does this remind you of your devil dreams in any

way?

T.: Mm-hmm (affirmative). It's like to some extent; he looks like that, like... you really can't see the details of him but he's sort of shaded too. That's what he looks like.

Dr. B.: So that -- and that -- how does that affect you in your dream and then looking at it now? What emotion does it cause?

T.: Oh, hate (her mind is flooded with (hatred).

Dr. B.: Hate? Yeah. Okay. And now B31 reminded you of death. In what way does it?

T.: Because it looks like shadows of a family and -- but ghost like (In her devil dream she and her were both killed. She also has had homicidal impulses when witnessing her mother beating her brother. Moreover she feared for her mother’s safety when intoxicated and involved with abusive men).

Dr. B.: Right. Do you think about death much in terms of your family?

T.: Not as often as I used to.

Dr. B.: What way did you use to?

T.: I used to be scared of death and think of it all the time, scared that something was going to happen (Her mother had treatment and had maintained sobriety for two years prior to this hospitalization).

Dr. B.: And who were you afraid would be visited by death in your family?

T.: My family my mom and my brother.

Dr. B.: How about your own death? Do you think about that much?

T.: Yes.

Dr. B.: What sort of thoughts?

T.: Of killing myself.

Dr. B.: And those are thoughts you had in the past or do you still get them occasionally?

Dr. B.: Right. Okay. And then B15 was the third one and you saw.....

T.: Oh, no, that's wrong.

Dr. B.: Oh. Well.....

Dr. B.: Uh-huh (affirmative).

Dr. B.: And it's being thrown at what?

T.: At something.

Dr. B.: What did you scratch out?

T.: I don't know.

Dr. B.: Okay. And what were your thoughts sort of like?

T.: Because it makes me sad to know that kids draw stuff like that. It means they're troubled (The “kids” represent a projection of her image.).

Dr. B.: Mm-hmm (affirmative).

T.: And I don't -- I like kids to be happy.

Dr. B.: In the dream, the nightmare, the devil cuts your brother or how did he.....

T.: Mm-hmm (affirmative).

Dr. B.: And what did he use?

T.: Well, using his hand.

Dr. B.: He didn't have a knife or.....

T.: Like he -- just like he had powers.

Dr. B.: It was done through magic or evil magic.

T.: Mm-hmm (affirmative).

Dr. B.: Mm-hmm (affirmative). Yeah. When you're cutting on yourself with a knife, how do you know what's it like?

T.: It just relieves my emotional pain (witnessing the blood and feeling the physical pain - while intense, it took her mind off the greater suffering that she was tormented with emotionally).

The analysis of dream imagery can often be of great clinical importance. However, consistent with Einstein’s observation, such images are not readily “countable” for statistical analysis. It may be recalled that there was a significant discrepancy in the number of devil dreams reported. At one stage she spontaneously referred to many such dreams, but later she could only recall one other.

The nature of the dreaming state has since been extensively studied. This work ranges from studies which focus on the psychological to those whose orientation is primarily biological. In attempting to provide modern theoretical pathways for integrating the two levels, Reiser (Reiser, 2001) recently surveyed the literature in attempting to conceptually bridge these two levels of enquiry. In response to Reiser’s review Zuk and Zuk (Zuk and Zuk, 2002) cited certain problem areas for investigators.

One concerns communication difficulties since when neuroscientists and psychoanalyst talk about “the dream”, “affect” or “emotion” the terms mean different things. They also observed that “REM, while an interesting phenomenon and the subject of much excitement by neuroscientists, says little or nothing about the meaning of the dream”. Also, they pointed out that Reiser’s review clearly indicated that “Freud”s notion of the dream as wish fulfillment is either incorrect or a gross simplification that fails to take into account alternative motives”.

To partially consider the conceptual framework for the present case history study, perhaps it might be helpful to cite the conclusions of William Domhoff, a well published dream investigator, whose research has relied heavily on content analysis approaches (Domhoff, 1996, 1999, 2000).

He recently summarized certain of his observations as follows:”Based upon solid empirical studies concerning (1) the neural network that makes dreaming possible, (2) the development of dreaming in children and (3) the everyday content of thousands of dream reports, it is unlikely that dreaming is “necessary” or that any clinical theory of dreams has any value beyond that dreams contain some psychological information”.

Recognizing the complexity of the field and the multiple methodological problems, it is hoped that the “Lucifer” dream under consideration provides in Domhoff’s terminology “some information”. For years this adolescent girl was severely abused by her Native Alaskan mother. Her culture is disintegrating rapidly. There is a high prevalence of alcoholism and violence related behaviors. Adolescent males have the highest rate of suicide in America so her fears for her depressed brother were justified.

During childhood development multiple sources of sensory input from this abuse were recorded neurochemically. However, the secondary recall of such traumatic images apparently had failed to appear in her recurrent “nightmares”. When asked on several occasions if she ever relived any of the terrible abusive scenes involving herself and her brother, she consistently said: No! Of course, there is no way to really know if this was the case. Perhaps she was aware of such dreams but because of emotional discomfort she did not want to report them. Alternatively, she may have been aware of them shortly after they occurred and then “forgot” them because of anxiety induced neural inhibition.

In any case, she was terribly tormented by intrusive memories of the abusive scenes during the day. In sharp contrast, her sleep was protected by symbolic images. One of these was the vision of “Lucipher”. No matter how terrifying this was, apparently it was less threatening than activating from memory storage real life images of her mother’s abuse.

Apart from the dream under scrutiny, she recalled only one other terrifying dream of the devil. She was able to recall that this occurred at age eleven: “I was in my closet and the devil appeared. He was small than and his brain was exposed, I was twisting a hanger around in his brain”. This disturbed her sleep when she was first attempting to understand her traumatic family life. Prior to therapy she was confused and mentally preoccupied: “Why does mother hate me so much? What did I do to deserve the beatings?

I must have deserved them. I should hurt myself. I don’t deserve to live. I should kill myself etc.” Her mental preoccupation with these issues caused her to focus on her own brain. She introduced this anatomical awareness into her dream imagery along with an object (the “hanger”) that she just had beaten with by her mother. This dream preceded her first hospitalization and suicidal behavior. At the time she was first beginning to get the almost delusional belief that some evil force from the devil was penetrating her nervous system accounting for her own demonic thoughts and murderous fantasies.

Sometime she would get angry at herself and would punish herself by self mutilating behaviors with knives. Her extreme arousal in viewing SIS-II video Image B15 depicting “Knifes” was understandable. This irrational thinking surfaced in the early stages of her fourth hospitalization in the “Lucifer” dream. It may be recalled that she related the onset of her sense of her body image being penetrated to when she originally played a Ouija Game. In association with the fundamental Christian mind distorting dogma that she had been exposed to in a Seventh Day Adventist church; she erroneously believed that the demonic forces had entered her body.

Apart from the devil symbol, many other threatening symbols flooded her dreams. Examples of such symbolic material spilling over into projective consciousness with the Rorschach in her third hospitalization six months earlier follow:

Card I:”A bear trying to escape from a very strong woman, she looks like my mother”. Here she identified with the “bear” and the “very strong woman” symbolized her image of her mother as being very powerful and threatening.

Card II “Two big animals playing patty cake. One is a bear and he looks like he is wounded because of the red blood”. The bleeding “bear” symbolized her own injuries from the severe beatings.

Card IV “A monster, this way it looks like a dragon here are his eyes, he’s got horns and wings” these two responses could symbolize her abusive mother. It also could have depicted that part of her emerging personality that was identifying with the demonic side of her mother. She also imagined it to be an “explosion with smoke coming everywhere” and gave a similar response to the next card. Both responses symbolized her memory of violent domestic scenes.

In addition and reminiscent of her attempting to hide in the closet from her abusive mother in real life and the symbolism inherent in running from Lucifer in her dream she this Card also evoked imagery as follows: ”It could also be a tunnel, something that you could hide in,” On card VIII the violent imagery continued to be released in projective consciousness as “A volcano with lava exploding”. On Card X this theme continued with the response “”This is a building, there is water below, in front these are fireworks going off, it is colorful, like fireworks going off, looks explosive here.”

Like many fundamental Christians, she had learned to personify the “Devil” and referred to him as “Lucifer”. To such concrete thinking people, it probably would seem pointless – if not heresy in her church - to try to understand what “Lucifer” symbolized.

This sharply contrasts with clinicians who explore dream symbolism as an integral part of the diagnostic/treatment process. In this analytic quest those who employ the power of projective methodology are much more likely to unmask the “Devil”. In the present study it may be inferred that “Lucifer” embodies both her mother’s abusive nature and that part of the adolescent’s personality identified with the mother. With regard to the latter, the responses revealed this side of her. One example was her response to SIS-I when she detailed how she had the capacity not only to hurt herself but others. Her extreme hatred and homicidal ideation was also symbolized in the “knife in the heart” response.

Apart from the satanic, there are many other forms of symbolic imagery in threatening dreams. For example, children frequently observe dream of grotesque human or animal like biting apparitions. They commonly label “Monsters”. The specific form of these is strongly influenced by the reality of their particular culture.

However, this earlier primitive oral aggressive imagery is replaced. This is especially true of severely disturbed adolescents with poorly controlled aggressive impulses. Perpetrated by the brain washing techniques of fundamentalist religious leaders satanic symbols can emerge in dream imagery.

The concrete thinking implicit in personifying the threatening humanoid figures as the “Devil” can be extreme. For example, satanic cults have evolved historically which in an organized fashion worship “Satan”. Personal identities of such members may be closely linked with socially unacceptable sexual and aggressive behavior. When their actions become day residual for night time dreams, a cycle of evil imagery and behavior becomes operational. Its reinforcement by the saturation of violence in the media amplifies the system.

Studies of anxiety laden dreams employing projective techniques can provide insights into the origins of violence in children and adolescents. Hopefully, such investigations could provide new approaches for developing more effective methods of early detection and prevention. Young people need to have their threatening dreams taken as a possible early symptom of trauma. They need to be listened to with compassion and serious consideration by members of the healing profession, as well as authority figures in education, religion and politics.

This is especially true for those from dysfunctional families where guilt and ignorance may allow their parents to dismiss their suffering by denial and rationalization. For example, the abusive mother in this case history study argued that:” I did not abuse my children, they were just getting the punishment they deserved” and in regard to her daughter’s terrifying dreams “They mean nothing, all children have nightmares!”

Her rationalization was not challenged. She herself was a victim of childhood family abuse. Such a generational pattern of abusive can only be broken through early intervention therapies – including the use of projective techniques.

Somatic Inkblot Series-I was administered to three patients who were not responding with medical treatment. The SIS was able to identify deep seated conflicts which patients were unable to uncover through conventional therapy. The usefulness of therapeutic tool of reframing along with hypnotic relaxation is also demonstrated with the help of three case studies.

“What is learned and remembered is dependent on one’s psychological state at the time of the experience” (Rossi, 1986). Accessing the state-bound memory or experience, creates an opportunity for growth through reframing or reorganizing it to facilitate some resolution. This is achieved through the recreation of the emotions, sounds and thoughts related to the repressed event or experience. Accepting the concept of state-bound memory, the therapist strives to create for the patient an opportunity to access the state bound sources of the problem. Hypnosis is one way of helping patients to access state-bound memories. All patients however are able to access these memories. This paper illustrates the use of the SIS as a projective technique and an adjunct to hypnosis, to help patients access the state bound memory, when conventional therapy is unable to achieve the same result. A three-stage administration technique is used. The first step is to administer the SIS cards and for the patient to identify the three cards they found least disturbing and the three cards they found most disturbing. The second step is to induce a light trance. Depending on the severity of the condition, the author would either induce a light trace or a deep one. The patient is given suggestions of relaxation and the state of relax is then anchored in the fingers. The third step is to ask the patient to open their eyes, look and concentrate on the card and close their eyes again. The patient is asked to report what emotional responses the card evoked or what images came to mind. Three vignettes describe the use of the SIS to access state bound memory. The cases described are of a woman with marital problems, an anorectic child and a woman with chronic anxiety. Once the memory was accessed and reframed, the patients showed a dramatic improvement in their condition. Case (1): Mrs. E.D. is a 38-years-old married woman who was referred by a colleague because she was not responding to conventional treatment and hypnotherapy for the complaint of marital and sexual problems. She dated the onset of her problem to nine years prior to being seen by the author after having had a Pap smear. She reports that she was embarrassed by the examination and had difficulty opening her legs. The examining doctor made derogatory remarks about her being sexually active as a single woman. She is married for two years to her boyfriend of 12 years and has a 2-year-old son. Her husband had visual problems. After extensive therapy by a colleague, which included hypnotherapy the patient showed no signs of improving? She was referred to the author for hypnotherapy. At the initial interview the SIS-II booklet was administered after taking a partial history. The following is what the author considered were some of the more significant responses. A3 I don’t know. A4 Left-hand side looks like a rose bud starting to open. A5 Looks like a small body, length and arms. This is the mouth. Like this person is confused like me.

A7 Someone drawing could also look like the fruit being hanged, looks like me moving my body away.

A8 (After a long silence), looks like a figure as well, like a pregnant tummy. Looks like sperm. Pinokio’s nose growing.

A12 An ear could be someone always wants to listen.

A22 Looks like a head cut apart, some object, two heads that were put together but separate.

A26 Looks like a deformed face, I see the eyes, or it could be a scan, a baby, development taking place.

B1 Head of a baby, flames, picture depicting the moon from space, whirlwind.

B10 Scan of womb showing developing fetus, pregnant stomach.

B15 Confusion, a child’s scribble, danger, dangerous pointing.

B30 Ears, there will always be someone who will listen to you.

By looking at the responses, the author formed the hypothesis that the patient was feeling confused and was asking for someone to listen to her story. The frequent references to babies were difficult to interpret. Because hypnosis was the treatment of choice, the following two sessions were spent clarifying any misconceptions the patient might have about hypnosis and to let her experience what it feels like to be in a state of relaxation and to provide her with an anchor for relaxation. This was done with the full knowledge that the referring colleague had used hypnosis and that the patient was familiar with the technique. the primary objective was to establish a rapport and to introduce her to my way of working.

Session 4.

Two options were considered; one was to explore the responses to the booklet in greater detail or to administer the SIS cards. The second option was decided on as a further diagnostic tool. The following are her responses to the cards.

Card 1.

Patient Could be a young girl with ponytails. Could be two birds. Young girl’s eye look a bit sad.

Patient: I do not know. May be she wanted something she was not allowed to get.

Patient: My mind goes back to when I was 10 years old. Mother had cancer; I knew she was sick when I was nine. I knew she had pain. I did not realize that she had died. I knew she had to go to a hospital. I knew she was in pain, I insisted that she plait my hair. When I left for school she wanted me to kiss her, I refused to kiss her.

Comment: At this point the patient became very quiet and tears rolled down her face.

Patient: At school the principal called me, I thought it was my uncle who had open heart surgery, I thought Uncle Bobby had passed away. When I got home my grandfather told me, my mother was gone. My grandfather was crying. At the funeral I refused to look at my mother in the coffin. I feel sad. I often think about her. I am sad; I did not kiss her good bye. My greatest fear is that I lost my mother; I hope my son does not lose me before he is 18. I think of her quiet often. My grandfather had two daughters.

Comment: On a further questioning patient told the therapist she had two photos of her mother displayed in her house and that she was sexually active before the marriage.

Card 2.

Patient: Little boy with a big face, there is a smile on his face. There is a smile but no eyes I cannot read the expression. I do not know if it is a smile or not or they are just stretching their lips.

Patient: A person not saying her true feelings, just smiling, a smile on her face. I am always smiling don’t let anyone know.

Patient: He insisted. After a year I proposed, maybe it was the sexual thing, after a few years he wanted to get married. I made up my mind; no I did not want a big wedding. I never had my parents. I fell pregnant; he said we had to get married, as his uncle did not want another child out of wedlock. I was 35, I was single for a long time, I felt free. At 18 my husband started having problems with his eyes. I have accepted his condition, I am proud of what he had achieved. I feel it is too much, I feel if I do not help him he will leave me. I went into this relationship knowing his eyes were bad. He had a drinking problem. He wants another child.

Card 3.

Patient: Another face, longish hair. Person is contented, could be a little bit (could not make out what the patient said) I don’t know why I said that. It dawned on me she is asking me a question, Do you think she did the right thing I want to say yes, maybe I did not forgive XX (She mentioned her own name) for what she did.

At his point the hour was over and the patient was distressed. The session ended with the patient being relaxed.

Session 5.

Conclusions drawn from session four were that the patient had some separation anxiety. There was guilt about her mother’s death and her refusal to kiss her goodbye on the day she died and she had some unresolved conflicts about her premarital sexual activities. The author decided to use hypnosis to help her to work through these conflicts. Routine induction was done with systematic relaxation. Using age regression and visualization the patient was able to “talk” to the 10-year-old girl and reassure her that young girls react on impulse some times and that she could forgive the 10-year-old girl for what she did.

Session 6 and 7.

During these sessions hypnosis was used to complete the grief work and help her to resolve conflicts related to her mother’s death. Some ego strengthening was also done.

Session 8.

Patient reported that she was feeling relaxed and had visited her mother’s grave and was able to complete her ritual of separation and felt proud of her achievement. She reported that she had applied for a promotion post and requested some assertiveness training to prepare her for the interview. She still had the fear of dying. Basic stress management techniques were discussed.

Session 9.

She reported that she was able to make decisions with confidence and only spoke very briefly about her marital problems. She was concerned that her husband was very friendly with a colleague at his work. She promised to phone to confirm the next appointment. The patient defaulted and did not return to therapy.

The case demonstrates the usefulness of the SIS in identifying deep-seated conflicts which patient was unable to uncover through conventional therapy. The usefulness of the therapeutic tool of reframing is also demonstrated. The patient presented with marital problems but did not respond to conventional therapy aimed at the "problem". The SIS helped to identify the underlying unresolved grief. Once this was dealt with and reframed, the patient was able to continue with her normal duties. Because the patient terminated therapy no follow-up appointment was given. It is interesting to note that only 3 cards were used in this case. An unknown factor is the author does not know whether any of the other cards would have uncovered some other conflicts. Because of the patient's improvement the matter was not pursued

Stimulus Plate SIT-1: Core Somatic Grief / Central Structural Focus

J.P. was an 11 year old boy who was referred to the author by his mother because he was not responding to previous treatment for an 11 year history of primary enuresis. He was extensively investigated medically and was exposed to various recognized treatments for enuresis. He did not respond to medication which he was on for 6 months. The parents had a discordant relationship when J.P. was about 5 years old but they have a good relationship now. Mother was concerned because J.P. was wetting the bed every night.

Session 1.

During the session a routine history was taken and basic information about hypnosis,

the treatment of choice by the author, was explained to the parents.

Session 2.

By means of a diagram the author explained the basic working of the brain with particular reference to the controlling function it has. Hypnotic induction by means of systematic relaxation was done. While in trance suggestions of control by the brain were given with a post hypnotic suggestion that whenever he is asleep and his bladder is full he will wake up to go to the toilet. A 2 week follow-up appointment was given. Mother phoned the author to report that J.P. had only wet the bed once during the week but had wet the bed over the week-end.

Session 3.

This session was used to reinforce the suggestions given during the first session and a 2-week follow-up appointment was given. Mother phoned after a week and a half to report that J.P. was back to wetting the bed daily. A third session was arranged.

Session 4.

Because of J.P.’s resistance to treatment it was decided to administer the SIS-I cards to see if there was any underlying dynamics that was missed. The following are the responses to the cards :

Card 1. A sheep, a goat.

Card 2. Looks like a person who is smiling.

Card 3. Two people who are dancing or something.

Card 4. Looks like a person who is doing, he is walking. I don’t know.

Card 5. Looks like a star.

Card 6. Looks like birds.

Card 7. Heart.

Card 8. Looks like a skeleton of a person.

Card 9. Kidneys.

Card 10. Looks like a snail.

Card 11. Looks like a heart.

Card 12. Looks like a body or something.

Card 13. I don’t know, looks like a heart turned upside down.

Card 14. Looks like an eye.

Card 15. Spine.

Card 16. Eyes and nose.

Card 17. Looks like a fish swimming in the sea.

Card 18. Looks like a monster’s face.

Card 19. Looks like a cockroach’s head.

Card 20. Looks like a face.

He liked cards 20, 4, and 19 and did not like cards 5,13 & 3 .

The technique used by the author is to induce a light trance and to ask the patient to look at the cards and while in a relaxed state to say what it reminds them of. The following are the responses while the patient was in a trance. The responses to the cards he liked were.

Card 4.

A body moving, that is all.

Card 19.

No response, the patient just looked at the card and did not respond to any probing question by the author.

Card 20.

Looks like a monster.

There responses to the cards he did not like were:

Card 3.

He just looked at the card with no response.

Card 5.

He just looked at the card with no response.

Card 13.

He looked at the card and said nothing.

Patient: Someone playing around in the park. Person is happy.

Patient: Because he is with his friends.

Patient: A persons face, makes me frightened. (Silence).

Patient: Because I get scarey ... silence.

Patient: Yes.

Patient: I'm scared of the dark.

The patient could not recall any incident that could have precipitated his fear of the dark nor could he remember how old he was when he first became aware of this fear.

With the patient still in hypnosis he was regressed to an earlier age. He identified the age as 2 years, he was alone and afraid. He did not know why he was afraid and there was no one who made him afraid. Using the reframing technique, the 11-year-old boy reassured the 2-year-old boy that it was normal for a young child to be afraid of the dark. The therapist had the 11 year old boy "talk" to the 2 year old until he was sure that the 2-year-old boy was no longer afraid of the dark. The patient was relaxed and reassured. He was asked to open his eye and look at the card 13 a second time. The following is his response:

Patient: People are dancing.

Patient: They are feeling happy.

Patient: Someone got married.

Patient: Yes no one is sad.

Therapist: Does the card make you feel unpleasant.

Patient: No.

Patient: No.

The patient was given the suggestion of deep relaxation and a post hypnotic suggestion that he was not afraid of the dark any longer. The patient's fear of the dark was discussed with the parents and they agreed to place a night light in the room. Two weeks later the mother phoned the therapist to report that J. P. had been dry up to then. One month after the termination, the patient was still dry.

Stimulus Plate SIT-7: Exhibitionism / Body Boundary Perception

Mrs. J. P. is a 52-year-old married woman with an 18 years history of anxiety and depression. Different general practitioners with various medicines with no symptomatic relief treated her. She has one daughter prior to her marriage and 4 children born within the marriage. Her husband and daughters has formed an alliance against the patient and she reports, "I feel very alone". The symptoms she complained of were suggestive of a diagnosis of chronic free-floating anxiety.

At 10 years she started sleepwalking and from the age of 15 yrs she was afraid of going to sleep at night. She married at the age of 25 yrs and reports that she is still afraid to go to sleep at night and suffers from agoraphobia. She has a recurring nightmare or seeing her mother in a coffin and of her asking her mother to open her eyes, as she is not dead. Her mother died when patient was 42 years old. Patient has a pronounced stutter whenever she has to speak in public. Because of the severity of the symptoms the author decided to concentrate on symptomatic relief. The first 3 session were devoted to taking the history and to teaching the patient the technique of self hypnosis, anxiety management and stress management. At the end of the third session the patient reported no relief in the severity of the symptoms. The author decided to administer the SIS cards to identify any underlying conflict that the patient was unable to access.

Session 4.

The following are her responses to the cards see identified as most liked and those she did not like: She found cards 2, 4 and 6 least disturbing and cards 18, 19 and 20 most disturbing.

Card 2. This looks like someone very happy, a smiling person.

Card 4. This seems to be another kind of dancing, laughing figure to me.

Card 6. Looks like someone kissing, two shapes, there is a feeling one wants to get close to the other one.

Card 17. This is a spooky something, scary something with pinches.

Card 18. This is another scary thing, looks like a nasty animal ready to fight.

Card 19. Oh mmmm looks like a bad face with a mask on, an evil face.

Card 20. Another ... like a vicious dog wanting to pounce.

The exploration of the cards was done at the following session.

Session 5.

The method used to explore the cards is to induce a light trance and to get the patient to open her eyes, focus on the cards and report what the card reminded her of. The author decided to start with the cards least liked by the patient.

Card 18.

Patient: I see a coffin; my uncle is in the coffin.

Patient: I am 12 years old. They want me to touch him. I am afraid.

Comment: At this point tears started to roll down her face. The reframing took the form of helping the patient to let the 52 years old person comfort the 12 years old girl, in her mind, by telling her that it was normal for a young child to be afraid to touch a dead body. The 52 year old had to continue comforting the 12 years old until she was sure that the 12 years old was no longer afraid. When the patient indicated that the 12 years old was no longer afraid the following card was shown.

Card 19.

Patient: A man's face, cruel, (a long pause).

Patient: Vicky, my child's farther. I loved him so much and he left me. I could not say goodbye.

Patient: He hurt us so much; the two of us (long pause).

Patient: I was too poor, he wanted lots of things. When I told him I was pregnant he told me he could not marry me. He said he was going to marry (X) and that hurt me. He just left.

Comment: The patient was very distressed at this point and there was a long pause. The therapist has made the patient compose a letter in her mind, to her ex-boyfriend. In the letter she had to tell him how she felt when he left her to marry another person, she also had to say good-bye to him in her own way. When she had "written" the letter she had to visualize giving the letter to him and watches while he read it. When he had read the letter she could if she wished say a verbal goodbye or she could just walk away. She did not share with the therapist what she did.

Card 20.

Patient: (She started to cry loudly and uncontrollably) I am scared, a scary face, someone wants to bite me, I don't know, someone wants to hit me. He looks black, big white eyes.

Patient: I am 4, I see a man (pause).

Patient: He is taking me by the hand, going into the house, on the bed ... taking off my panty ... he is going to cut me. Not going to cut. He is patting me, on my private. He is saying it is all right. I am not afraid anymore. I get up, walking out of the door; I'm going home (patient is crying aloud freely now). I'm scared to go home. My mommy's going to hit me. I'm out side; I'm not scared anymore. It's O.K. its "Mal Willie" (Mad Willy). He's putting me on the swing. I'm so scared of the swing, I am scared, and why is he pushing me so high. I jump off; I'm falling on the tar. My leg is bleeding. I'm scared. I'm so scared of the man he is so big. I'm going home. I'm at home. It's O.K. I'm not scared anymore. My mommy is there in the kitchen. I'm in the park, I see him again, Mal Willie (Mad Willie). I'm not alone; I'm not scared of him anymore.

Comment:

The patient had settled down by now and became very quiet. The therapist reinforced the suggestion of deep relaxation and reframed the incident by helping the patient to visualize the 52 years old adult comfort the 4 years old child. She had to continue to talk to the young child in her mind and to reassure the child that it was normal for a 4 years old child to be afraid of an adult who does things they are uncomfortable with. She had further to reassure the 4 years old there was nothing she could have done and that she was not to feel ashamed of what had happened. The patient had to continue talking to the young child in her mind until she was satisfied that the young child felt comforted. After a period of silence the patient settled down. The session ended with the patient being relaxed and being given a post hypnotic suggestion that she would remember only those things that were comfortable for her to remember.

Session 5 was held 3 months after session 4 because it was over the Christmas period. At this session the patient no longer had free-floating anxiety. She did however; complain of situational anxiety with relation to her husband. The patient terminated the therapy. She contacted the author again 18 months after terminating for a completely different problem.

These cases demonstrate the usefulness of the SIS in identifying deep-seated conflicts which patients are unable to uncover through conventional therapy. The usefulness of the therapeutic tool of reframing is also demonstrated. In case one, the patient presented with marital problems but did not respond to conventional therapy aimed at the "problem". The SIS helped to identify the underlying unresolved grief. Once this was dealt with and reframed, the patient was able to continue with her normal duties. Because the patient terminated therapy no follow-up appointment was given. It is interesting to note that only 3 cards were used in this case. An unknown factor is the author does not know whether any of the other cards would have uncovered some other conflicts. Because of the patient's improvement the matter was not pursued.

In case 2 the young man did not respond to both therapeutic and medical intervention. The SIS cards helped to identify the very basic problem of a fear of the dark. Once identified it became obvious that this was a very logical question to ask. Everyone, including the author, was so concerned to treat the enuresis that no one thought of asking the patient if he was afraid of the dark. Once a night-light was placed in his room and his fear of the dark was reframed, the enuresis stopped.

Stimulus Plate SIT-7: Exhibitionism / Body Boundary Perception

It could be argued that the problems would have eventually been identified but at considerable emotional cost to the patients. These case histories have demonstrated the usefulness of the SIS cards to identifying deep-seated conflicts.

Divorce is one of the most traumatic experiences for both parents and children. In many cases the children are not aware of the intention of the parents to dissolve the marriage. Once the decision to divorce is made most couples find it difficult to approach life in a positive and constructive way. They experience a range of emotional and psychological consequences and many are very vague about their future. Communication between the couples can range from talking about the impending events to complete non-communication. The self-esteem of both or one parent is negatively affected and they may lose their sense of priority and tend to be problem and circumstance driven (Hoffman and Pincus, 1989).

The child’s reaction to parental divorce is one of confusion and depends to a large extent to whether or not they are informed about the reasons for the divorce. It is unavoidable that the child will be in the middle of a custody dispute that exposes them to additional trauma. The anger and hostility between the divorced parents make it difficult for children to face life with any degree of confidence. It is not surprising, therefore, that these children often display aggressive behavior. They have difficulty to display affection to others and fear to become emotionally attached to others. Anxiety and depression are common manifestations in the lives of these children.

They age of the child will determine to a large extent how they will react to parental divorce. The toddler will realize that one parent no longer lives at home. Preschoolers and early elementary school children are more likely to blame themselves for the divorce. They will display feelings of sadness and will mourn the loss of one parent. Preteens and adolescents feel abandoned by the parent who has moved out. They will display a range of emotional responses. They may become aggressive and rebellious, will feel angry and some will have to prematurely assume adult roles.

While therapists can have a dynamic formulation about the reasons for a patient’s they can never be absolutely certain that they are correct. The value of the SIS lies it it’s ability for therapists to allow the patient to reveal emotions that would under normal circumstances will remain hidden (Cassel and Dubey, 1997).

Case study:

The patient is an adolescent , referred by a doctor, who had been treating him for sports injuries. Six months prior to his referral the patient developed respiratory problems. He reported that he could not sleep because of his difficulty with breathing. His mother reported that she and her husband divorced almost five years prior to his referral. Mother further reported that whenever she wanted to go out that the patient would complain about difficulty in breathing.

The patient reported that the parental divorce made him feel very sad because his father had left the house. He knew that his parents were going to separate but his father left without formally greeting him. He felt that his parents did not really love each other. He reported that he would frequently get up during the night to make sure that his mother was in the house and that nothing had happened to her. He described his symptoms as a tight feeling in his stomach followed by his gasping for air. He would have a feeling of impending harm to his mother. He dated the onset of the symptoms to just after his parent’s divorce. He was ten years old at the time.

Dynamic formulation:

The author hypothesized that the patient’s symptoms were related to the parental divorce. The patient was afraid of loosing his mother as well and he had negative angry feeling towards his father. He somehow felt responsible for his mother and had guilt feeling about his anger towards his father. The panic attacks were neuro-psysiological responses to his fear feelings of guilt and his fear of losing his mother.

Intervention plan:

In order to confirm the dynamic formulation the author decided to administer the SIS cards. The following are his responses to each of the cards.

SIS Responses:

Card 1: I see a cow, this is the head and horns ... standing on a stool, like blood. That blood is from its head because part of his body is gone.

Card 2: Somebody smiling head big smile, arms and feet. He is just happy, he won something. It is nothing that he did he is just happy.

Card 3: I see a lady and a man, they are holding hands together. They are running. Running to get objects, apples.

Card 4: Somebody playing soccer, the head, there is the ball.

Card 5: Looks like a sumo-wrestler sitting on a stool. He is anxious about something. Two children sitting on the side, two babies. Looks like he is falling down and this one looks like he is jumping. I don’t know why he is falling; he tripped to save him from falling.

Card 6: Looks like two birds singing, a child at the bottom looking at the two birds. I don’t know why they are singing. He is watching. He is outside in his garden or something.

Card 7: Look like a butterfly lying on his back. I think he is hurt or something. Hurt by a stone or something, got thrown; someone threw a stone at him.

Card 8: Looks like two animals eating another animal; here is the ribcage, the heart. Here is another animal. They caught the animal, like two lions killing a zebra. I think the animal suffered, not an instant death.

Card 9: Looks like two children drinking coke or something out of the same tin, cool drink. They felt like sharing with one another.

Card 10: I can’t see anything. Actually it looks like a lamp on a piano or something.

Card 11: I see a snake like in a tank. It’s just lying there.

Card 12: Looks like an eagle, wings, flying away.

Card 13: Looks like a heart cut in half. Heart upside down cut in half.

Card 14: Looks like a very deep hole going down. Somebody getting buried flowers o top of the coffin.

Card 15: Looks like a very tall person wearing a hat, a big one. Just standing alone. No reason, just wants to get away from everyone else.

Card 16: Looks like somebody’s face, eyes, nose, something coming out of the eyes, tears coming up not down. I don’t know why crying.

Card 17: Looks like somebody with a very long nose. That’s all I can see.

Card 18: Looks like a bat with pointing ears. Very black one.

Card 19: Looks like somebody putting on sunglasses. Looks like they are shouting. They look angry. They might be shouting at somebody. They did something wrong, looks very angry and at the same time very sad.

Card 20: Looks like somebody with a very big mouth, screaming, crying, and looks unhappy and angry. Somebody did something they did not like, they are shouting.

The patient reported that he liked cards, 2, 4, 9. He liked card 2 because, “This person is very happy, he won something”. He liked card 4 because, “This person looks like he is happy and is having lots of fun playing with his friends, having a good time. Finally he liked card 9 because, “They are sharing, not selfish, sharing with one another.

The respondent reported that he did not like cards 5, 8, 16. He did not like card 4 because, “I do not like the children falling while the father is sitting back, the other child is crying for help, dad anxious, not doing anything”. He did not like card 8 because, “I do not like that they had to kill something to satisfy their needs. The fact that they had to make the thing suffer before it was actually killed. He did not like card 16 because, “I don’t like somebody crying, it brings more pain into the person who is crying, everybody starts crying. I don’t like to see anybody sad”.

Interpretation:

From the theme that appeared to emerge from the cards that respondent likes and did not like I concluded that there was a deep need to be happy doing some activity with someone. His sadness appeared to be the result of some group activity where one member of the group is causing the others to be unhappy or to hurt. The interpretation was made that, based on the clinical history the respondent was affected at an unconscious level by his parent’s divorce. He had a deep desire to be happy but the feeling of hurt caused by the parental separation had a more profound affect than he was able to understand. His panic attacks were his way of trying to resolve his fear of losing his mother as well. This interpretation was shared with the patient and his mother. I explained that I proposed to help him to resolve these conflicts through the use of hypnosis. His mother was familiar with hypnosis and only a brief description was again given to her. I also explained to the patient what I proposed to do.

Hypnotherapy:

The therapeutic intervention was divided into five phases. Phase one consisted of a routine induction and to anchor the feeling of relaxation in his fingers, that is to give him an anchor. This would be followed by phase two which would use the technique of age regression to a time when he experienced some anxiety. Phase three would use the technique of visualization to work on his anxiety when ever his mother decided to or actually left the house. The treatment would conclude with phases four and five which would consist of some ego strengthening and a post hypnotic suggestion of experiencing a sense of achievement and of the anchor producing a sense of deep relaxation whenever it was used any time in the future.

Phase one: Routine induction and provision of the anchor:

A routine induction through the use of systematic relaxation was done. The state of relaxation was then “anchored” to the patient’s left thumb and first finger (held in the position when pinching something). The anchor was tested by letting the patient visualize a scene that he found anxiety provoking and using his anchor to reduce the level of tension. When I was satisfied that the anchor was effective I proceeded to the next stage of the intervention to deal with the conflict and pain of the parental separation. The techniques of choice were age regression and visualization.

Phase two: Age regression:

The unconscious mind was allowed to regress to an earlier age to any incident that was experienced as painful or traumatic. The unconscious regresses to the age of 7 years. From the history this was the age when the parent’s were experiencing marital problems. Mother reported that at that age the patient was competing with her for father’s attention. In hypnosis the patient described feelings of rejection and aloneness. His predominate emotional experience was one of sadness. The suggestion was given that the “patient of to-day” i.e. the 14 year old had to talk to the 7 year old and explain that it was normal for a 7 year old in that position to experience feelings of rejection and alones and to feel sad. The 14 year old was instructed to continue “talking” to the 7 year old in the quietness of his mind until he was sure that the 7 year old no longer felt rejected, alone and sad. When that state was reached the 14 year old was instructed to “tell” the 7 year old that he would always be there for him and take care of him. The 14 year old had to then imagine the 7 year old walking away from him but now the 7year old was happy and content. When he could no longer “see” the 7 year old he had to indicate to my in a way that was comfortable to him that the 7 year old was no longer “in sight”. At that stage the third phase of the intervention was done.

Phase three: Visualization:

The technique of choice for phase three of the treatment was the use of visualization. The patient had to visualize being at home when mother decided to go out. He was instructed to use his anchor to reduce the level of anxiety to a level that he was comfortable with. The visualization was repeated (about three times) until he no longer felt any anxiety.

Phases four and five: Ego strengthening and post-hypnotic suggestion:

During this phase the patient was instructed to visualize himself as strong and coping with no anxiety when his mother left the house. The post-hypnotic suggestion was given that he would have a sense of achievement referring to not experiencing any anxiety when his mother left the house and that whenever he used his anchor he would experience a feeling of deep relaxation.

Follow-up:

A three week follow-up appointment was arranged, however after three weeks his mother phoned to report that the patient did not experience any panic or anxiety since his treatment. I decided not to see the patient again. His mother was taken into therapy for an unrelated problem and after 8 weeks she reported that the patient was still symptom free.

An experienced therapist can usually be reasonably confident after taking a detailed history that their hypothesis about the origins of the psychopathology the patient presents is fairly accurate. However no one, not even the patient themselves can be sure of what the unconscious mind is guarding. To get a more accurate idea the therapist can make use of some projective technique to help them to get a clearer understanding of the dynamics produced by the unconscious mind. An accurate identification of the underlying unconscious dynamics goes a long way to speed up the treatment intervention because the therapist can focus directly on the underlying conflict without going through the process of testing the hypothesis and reformulating when it is rejected.

This case history illustrated that the SIS is a very effective as a psychodiagnostic tool and therapeutic aid. The therapist was able to help the patient to resolve his underlying conflict of his perceived rejection by father through the use of hypnosis without the patient having a cognitive understanding of his illness. There is no doubt that children are affected by parental separations, however each child is unique. The therapist has to determine how the child they are working with experienced the trauma. While the therapist has a choice of projective techniques to use should they so desire, the SIS has proved to be a simple and very effective tool in this case. It can also be concluded that not every case where parental separation can be treated through hypnosis the use of this therapeutic approach proved to be effective in this case.

Stimulus Plate SIT-12: Visceral Anxiety / Internal Organ Architecture

Mr. X 29 year’s, Ph.D. student, presented in July 1992 with recurrent loss to hair over scalp, arms, legs and trunk for last 23 years. His mother had history of alopecia areata and bronchial asthma. In view of alopecia totals, he was treated with prednisolone pulse 300 mg once a month for four months and had complete regret of hair (Sharma, 1996). Subsequently he presented with relapse of alopecia totals in July 1994 and gave history of stress due to conflict with Ph.D. guide. He was treated with topical sensitize diphencyprone and had complete regret of hair at 6 months and is on maintenance therapy for almost 3 years.

As he narrated, he was frequently given severe beating by his father to the extent of beige physically abused. He perceives his father to be very authoritarian, aggressive and dominant, therefore leading to frequent quarrels between his parents. He is aggressive towards his brother and sister. He finds it to be a broken family.

He has few friends and very limited contacts. He got familiar with a female university student and soon married her. It is a sort of arranged marriage by his friends, though his parents gave their consent at the end. Initially he was withdrawn from his wife as he was feeling sexually weak. There was problem of erection, which improved to some extent after medication. Medical treatment and supportive psychotherapy helped in improving his symptoms.

A few significant responses on Somatic Inkblot Test with content analysis are given below:

A5: He perceived this image as “A man crying for freedom with his body torn apart”. It bring out this inner cry and desire to get away from his broken family home/ He further confirmed this feeling during interview and therapy session. He finds his home worth living and wants to flee.

A10: He has viewed this image as “The face of a gloomy woman marred by distressful life”. It may depict his projection towards his mother who often received physical assault from his father and is depressed. The patient projects that most of the Indian families have such bad atmosphere. This may also bring out his sympathy towards her mother and his inability to help her because of the dominant father.

A13: He saw “The hand / palm of a person caught in a fire as if crying out for help”. Once again his inner cry has come out on surface indicating that he needs help from others. This may also be indicative of his wishful thinking to get support and help from his physician/ therapist for his physical symptoms in the form of alopecia or even sexual inadequacy.

A15: He has seen” An infant priced/pierced/stabbed by a long knife in womb itself’. This may be indicative of his regressive phenomenon, which takes the person back in time and he feels that it could have been better if he had died as a fetus. It suggests his depressive mood and that the person wants to bring the womb itself may also be indicative of severe pain inflicted by his father during his early childhood. Such information is very important for a therapist as it helps him in therapeutic intervention.

A22: He viewed it as a “scorpion” rather than seeing it as backbone or male genital organ. The plausible could be that because of his “impotence” he has avoided seeing backbone/ male sex organ even on suggestion. Since it is painful to think of importance to a newly married person, he has projected it as a ‘scorpion’ – a pain-inducing insect.

A23: He has seen” a baby scorpion”. Once again the imagery of male genital organ has been suppressed and painful imagination in form of a scorpion is brought out on the surface. The other possible explanation could be his injured “tailbone’ a few years before for which he had lot of pain and suffering.

A31: He perceived “A couple shares their common woes” on this image. Seeing a couple is the most typical response but “common woes” may bring out his inner cry particularly because of his sexual weakness ad inability to perform the role of a husband.

B4: He viewed on this image “A happy man but a woeful woman”, suggesting his projection of seeing his wife under woeful imagery. This may also be the projection of his mother whom he always finds in a miserable situating. Once again the theme of disturbed family life and his own withdrawal from reality as a deference mechanism has been brought out.

B11: He has seen “a wig kept on the heaps of a person”. This may suggest his fear of becoming “bald”. The loss of hair due to alopecia areata has created in him a lot of tension and he is worried to the extent of becoming bald. Such anxiety is quite expected in a young man.

B20: He viewed” The rear view of a head with long hair” which suggests his wishful thinking to have long hair. He further elaborates that he has seen his own photograph with long hair and wishes to have long hair once again.

B28: He has seen “A distressful passionate person” on this image, which people generally see as ‘a lady with her child’. Avoiding seeing a lady may be due to his conflict with his wife and “passionate person” could be the projection of himself.

B31: He has seen “A family with their children knitted together tightly out of some unknown uncertainty./fear/ upheaval or resolution” on this image. Since it is the last mage of the test, the theme of a happy family is projected on this image so that the person could carry positive feeling at the end of the test. Instead of seeing a happy family, he had seen a family with their children knitted together tightly – is a painful back in time to help him to process the painful memories of childhood. Physical abuse, lot of uncertainty and strict discipline might be a few of the reasons for such an imagination.

As a whole it can be concluded that the Somatic Inkblot Test had hoped the patient in projecting the painful childhood experiences, disturbed family relationship, and fear of being bald and disturbed physical/emotional relationship with his wife. The test had further helper in establishing the psychopathology leading to psychosomatic disturbances (alopecia areata) and the need for counseling.

Alopecia areata is known to be associated with emotional factors (Dubey and Das, 1977). In recent study from India emotional factors were clamed in 7 percent in inducing or perpetuating alopecia (Sharma et al, 1996).

These figures of 5 to7 percent emotional factors in alopecia areata suggests patient’s own view point but when a projective inkblot test like the Rorschach or the Somatic Inkblot Series was administered, altogether a different picture emerged as disused in the case. . It is painful to accept and reveal one’s own sufferings in front of a physician, but the patient feels comfortable to project his sufferings through the inkblot images and accepts this during interview and analysis.

Most individuals find it highly stressful to have a physician inform them that they have a life threatening form of disease. In the patient’s mind this medical information links disturbing affect to the symbolic mental representation of the diseased region. In susceptible people, such stress may precipitate a psychological syndrome having features of Posttraumatic Stress Disorder (PTSD). One may involve the experience of terrifying dreams depicting either in real or symbolic form cancer spread and death scenes.

If the disease process is visible on the surfaces of the body, memories of these may be reprocessed in PTSD dreams. Such sleep disturbing intrusive imagery may be comparable to that observed clinically, when real life traumatic visual memories are incorporated into dream affect and symbolism. Similar imagery may be activated when internal cancerous processes produce changes in appearance of body fluids or excretions. For example, the alarming sight of red blood bleeding from a body orifice can be vividly recorded in memory neurons during the day, only to reappear during disturbed sleep.

When a person is informed of having cancer, a collage of threatening material may impact their ultimate response. Most medical care providers are able to intervene with support sufficient to prevent such stress from precipitating the overt clinical symptoms of PTSD. Ordinarily the traumatic imagery may only appear in disguised symbolic form in minimally disturbing poorly recalled dreams.

In traditional practice medical practitioners and surgeons fail to enquire into the significance of such “Nightmares”. Sometimes a susceptible individual may experience extreme stress. This may activate the person’s mental defenses and convert unexpressed fears of death to medically inexplicable pain.

Psychological consultants who are trained in projective technique are better able to decipher disease related dream imagery and symbolic specific anatomical inkblot responses. Pathological anatomical responses with the Rorschach may signify irrational fears of cancer spreading and exaggerated death anxiety. Often the symptomatic individual may be psychologically blind to their body image significance.

Individuals suffering from Conversion Disorder pain frequently fall into this diagnostic category. It may be recalled that the diagnostic criteria for this condition involve the following four features:

A. One or more symptoms are present or deficits affecting voluntary motor or sensory function that suggest a neurological or other general medical condition.

B. Psychological factors are judged to be associated with the symptom or deficit because the initiation or exacerbation of the symptom or deficit is preceded by conflicts or other stressors.

C. The symptom or deficit is not consciously produced or feigned (as in Factitious Disorder or Malingering)

D. The symptom or deficit cannot, after appropriate investigation, be fully explained on the basis a general medical condition”.

E. The symptom or deficit causes clinically significant distress or impairment in social, occupational or other important areas of functioning or warrants medical evaluation.

F. The symptom is not limited to pain or sexual dysfunction, does not occur exclusively during the course of Somatization Disorder, and is not better accounted for by another mental disorder.

Case History:

This involves a 47-year-old married woman who was originally evaluated thirty years ago on the medical ward of a general hospital. Her referring internist requested assistance in management of her “Severe pelvic pain”. She had bizarre affect characterized by apparent indifference. Her referring internist had said her totally denying any fear of recurrence was like an “Ostrich with its head in the sand”.

At age forty-one she had developed Ulcerative Colitis, an inflammatory bowel condition whose etiology is poorly understood. It can result in abdominal pain, severe diarrhea, rectal bleeding and other severe health problems. In her case, it was bowel cancer.

Diagnostic evaluation indicated that she had clinical features, which met all categories for a psychiatric diagnosis of Conversion Disorder:

A. She had been hospitalized because of physical symptoms which could well be accounted for by recurrence of her bowel cancer. Her pain was experienced throughout the pelvis region, the rectal area, right hip and lower back. It was described as being a “very searing, hot jabbing pain” whose intensity “worked up and down”.

B. Her pain had developed two years earlier shortly after the stress of cancer surgery. During the operation the tumor had been completely removed and a temporary colostomy established. The cancer had not spread to other structures in the pelvis.

C. There was no evidence of her feigning illness.

D. Extensive medical diagnostic evaluation revealed no metastasizes or activation of her Ulcerative colitis sufficient to account for her severe pain..

E. Her symptoms restricted her domestic life and warranted hospitalization.

F. Following surgery she developed a somatic delusion. In a paranoid way she persisted in complaining, “The surgeon removed my tailbone”.

As noted what was remarkable about her overall clinical presentation was the great contrast between her extreme emphasis on pain and by contrast absence of any fear of dying from cancer.

This denial is illustrated by considering as portion of a tape-recorded interview:

“I had ulcerative colitis for quite a few years … and then it was … it would be four years ago … I believe it’s four years ago … five … no four … at Christmas time … all of a sudden after that I started to bleed from the rectum and I didn’t tell anybody or say anything about it until the middle of February … and they made me go see Dr. Z. and he set up a barium right away to look at things and when I was waiting for the results I flew to Vancouver and had a holiday with my sister … I was trying to forget about this for awhile but when I got back he told me that I was just like an ostrich sticking my head in the sand and not wanting to know what was the matter with me.”

Patient: It was cancer.

Doctor: I see.

Patient: And he (the surgeon) had a very good idea at that time that this is what it was … he just didn’t say …he wanted to be definitely sure.

Patient: You know I can’t remember him telling me this … not until after everything was over … I know my husband knew and whether they had me drugged and told me I don’t remember but I really don’t remember him telling me this until everything was over with … and it didn’t bother me because he said that he got it all … they told me I would be a new girl and everything would be fine … you know they gave me a temporary colostomy.

Patient: Well some people would worry and think well you know I’ve had this … maybe I’ve still got it and you know … but it didn’t bother me.

Patient: Oh … once in a great while I’ll maybe think about it but not really.

This denial mechanism also was evident when attempts were made to explore the significance of her PTSD dreams. After she learned about her cancer, she began to frequently experience dreams in which she died of some type of horrible disease. While she readily acknowledged that these “Nightmares” were upsetting, she repeatedly refused to accept that they might indicate that she was afraid of dying from cancer.

Rorschach Results:

Next attention might be given to her pretreatment body image as revealed by her anatomical responses evoked with Rorschach testing. Initially this projective procedure was administered in the traditional way with the following initial responses:

Three anatomical responses depicted pelvic imagery in her projective consciousness. Next the Rorschach procedure was modified prior to the detailed inquiry. This was done by placing all ten cards on a couch in front of her. She was instructed to arrange them in order from those, which were “most upsetting” to “least upsetting.”

She arranged the series in the following order: X, VIII, IV, V, III, VII, IX, I, II, VI. Card X was extremely upsetting to her. Next she was told to rate the emotional threat that the series evoked on a scale from zero to one hundred. She was instructed to imagine the highest rating as being the “most upsetting thing she ever experienced in her life”. Reflecting the high degree of anxiety linked to the symbolic imagery, she assigned a value of ninety-nine to the card.

Changing the order of administration undermines the applicability of statistical norms and obviously has disadvantages. However there is an overall positive tradeoff in working with somatic symptom related anatomical responses. It incorporates the relative degree of affect –image linkage. This summation can increase the Rorschach’s projective pulling power on clinically relevant, yet otherwise daytime dormant PTSD dream imagery.

Essentially it treats the ten inkblots more as an overall visual gestalt. In this model, affect bonding between cards serves to supplement projective symbolic cognitive linkage in the associational chain. This administration procedure maximizes the projective “pull” of the cards. Moreover it makes for logical coherence in the associational chain to begin with projective responses associated with the highest level of arousal.

The results of the detailed inquiry follow:

Card X:

Patient: “Down here (pointing to central red configurations) … this is part of the pelvic region to me … this looks like it.”

Patient: “Yes … and I always think they are just attacking … I just … it really bothers me … that picture really does.”

Card VIII:

Patient: “These look like rats or something like that (pointing to the red objects on the sides of the ink-blot configuration).”

Patient: “Yes.”

Patient: “Well they are attacking too … it looks like they are going in and either eat you up or do something.”

Patient: “Well this is again the pelvic region (pointing to the lower area of the ink-blot configuration). A little bit higher up … to me this is more down here in the pelvic … they’re going up a little bit higher.”

Patient: “A little bit higher up into your stomach, up into your lungs kind of.”

Card IV:

Patient: “Well this looks like a monster of some type … it would be an immense bug or something.”

Patient: “Well it just looks like it’s going … well I don’t know … it just feels like it’s going to do something bad … like it’s going to attack again.”

Doctor: “What is it going to attack?”

Patient: “Well again all of these pictures remind me of the pelvic area. I feel that this is where they are attacking when I look at these pictures.”

Card V:

Patient: “That to me looks like a great big bat … and I don’t know if it’s because of the radio and TV … I always think of vampire bats.”

Patient: “And sucking blood out of people which I don’t really know if they do or not … that’s what bothers me about that.”

Patient: “Well again … you know because of this down here … it looks again like it’s going down to the pelvic region … the bottom end of the bat … you know if you look at it in another way it still looks like it’s part of it again.”

Card III:

Patient: “Well they just … they … they look like something from outer space not like something real … like something unreal and it looks like they’re … whatever they’re doing it’s making this person lose blood somehow and it’s dripping down.”

Card VII:

Card IX:

Card I:

Card II:

Card VI:

Initially an interpretative cognitive psychotherapeutic approach was planned, using the Rorschach. In contrast to the SIS the ten inkblots have relatively little color form structure suggestive of anatomy. When there is a clear mental perception set focusing on a region, there may not be a need to follow-up with any more anatomically structured forms of the SIS.

In any case, in interpreting her Rorschach pelvic image fixation, it was suggested to her that the “Attacking” creatures might symbolize in-depth fears that the surgeon had not succeeded in removing all the cancerous tissue. Perhaps predictably, considering the intensity with which she focused upon the pathologic body imagery and pain, she chose to reject this interpretation by saying “Well these are just pictures I am looking at like I’d buy in a store … they don’t have to do with my pelvis”. In this manner, her mental defense mechanism blocked unreported fears of recurrence and death anxiety.

Since this strategy did not appear to be productive, a second treatment approach involving behavioral therapy designed to desensitize body image anxiety was planned. This procedure involves gradually reconditioning the symptomatic individual to an anxiety laden hierarchy of anatomical images, while in a state of deep relaxation.

Because of the highly threatening nature of her dream and Rorschach imagery, sedating doses of Sodium Amytal were injected intravenously in six subsequent viewing situations. On each treatment day she was exposed to the Rorschach cards, in order of ascending anxiety, for thirty seconds with a thirty second relaxation pause in between.

In the latter sessions, the symbolism on Card X was much less threatening. The “attacking” organisms were portrayed as being more placid, more often lying down, and less likely to attack. This was clinically correlated with a comparable reduction in her pain and a willingness to more realistically consider her cancer free prognosis.

This case brings to mind some of the early views of conversion hysteria. In 1907 Janet originally introduced the concept “dissociation” to account for the underlying psychopathology (Janet, 1907). He referred to a “retraction of the field of consciousness and a tendency to the dissociation and emancipation of the systems of ideas and functions that constitute personality.” In this manner the individual no longer was considered to have access to the dissociated ideas, which permeated his mind. However, these were considered to be mentally active operating autonomously to create the symptoms of hysteria. Freud’s psychoanalytic work on hysteria is also of historical relevance (Freud, 1953)

These would still appear to have historical merit for building a modern foundation for conceptualizing of Conversion Disorder. Janet’s formulation is particularly theoretically helpful in accounting for the discrepancy in the data obtained using interviews versus projective technique. The verbal report suggested that there was no fear in conscious awareness of cancer metastasizes. This affect void is reminiscent of what in the past was referred to as “la belle indifference”. In the classical cases manifested minimal overt anxiety but manifested bizarre and dramatic symptoms involving pain and paralysis.

The history of projective technique in the diagnostic/therapeutic management of Conversion Disorder is also relevant in the present case history study. Rorschach’s original thinking about the significance of moving anatomical responses depicting movement warrants conceptual reexamination. Herman had begun to consider that these somehow might reflect a direct projection of kinesthetic sensations in the viewer’s own body. His creative thinking resulted from recalling a vivid dream experienced as a medical student (Ellenberger, 1954).

In my first clinical semester, I was for the time at an autopsy and looked at it with the well known respectful eagerness of a young student. The dissection of the brain interested me particularly, and I joined to it all kind of reflections about the localization and cutting up of the soul. The diseased had been an apoplectic; the brain was cut in transverse slices. The following night I had a dream in which I felt my own brain was being cut in transverse slices. One slice after another was cut off from the mass of the hemispheres and fell forward, exactly as it had happened at the autopsy. These bodily sensations (I lack a more precise designation0 were very clear, and the memory of that dream even now is fairly vivid.

This dream shows that Rorschach early in his professional training needs to be praised for attempting to formulate a body-mind-spirit conceptual model. His attempt was modeled after the worthwhile work of early anatomists and neurophysiologists to localize brain functions in specific neural structures. While this proved immensely helpful for certain basic processes, such as those underlying movement and sensation, it has not proven nearly as successful for higher brain functions.

This is especially true for formulating a brain-mind model for understanding more about the “Soul”. There now is a scientific literature reviewing the positive influence of various healing religious practices. Yet we lack nomenclature and theory. The present authors view certain types of dream imagery as arising from an energy source outside the individual’s conscious control. It would appear to have come from a natural healing spiritual source (“God”?).

It is suggested that this interpretation may apply to Herman’s dream. The fact that that years later this dream kept intruding on his mind is pertinent. For one thing, it inspired him to postulate that movement imagery was based in biologic sensory roots. Remember his body-mind state that when he first viewed the imagery. He was a passive sleeper without access to his own volitional cognition. He was therefore in error when referring to it possessively as “his” own dream. It represented a symbolic message from a higher spiritual power. In reality he should have given thanks to the higher power, which inspired him. Most of us make the same ego based mistake in claiming personal credit for inspirational gifts from our spiritual source.

In any case, his “vivid” recall brings to mind the features of what now we understand to be clinical characteristic of PTSD dreams. It may be inferred that the original autopsy scene witnessed as a young inexperienced medical student was highly stressful. Due to the initial shock some students actually faint during autopsies. In all likelihood Herman’s empathetic connection with the diseased had caused him to partially identify his own body gestalt with the body being dissected.

At the time of the original trauma he was particularly interested in seeing the pathologist dissect the brain. When observing this, his mind was preoccupied with “reflections” about “the localization and cutting up of the soul”. His memory of the original scene’s visual imagery highlighted movement images from the dead person’s brain sections falling apart from the dissection. In the dream, he subjectively experienced these as kinesthetic “body sensations”. Of course, at that early scientific period in the last century had problems describing his subjective experience (“I lack a more precise designation”).

At this stage in the twenty-first century there is available a richer language for scientific communication about body-mind-spirit processes involved in inkblot perception. One can now conceptualize of a person having an overall gestalt of the body with shifting levels of awareness for this, as compared to external objects in the external field of perception. Within this somatic field of consciousness various regions compete for registration in full awareness. Sensory feedback factors can influence this process. For example, consistent with Herman’s original view, sensory feedback of kinesthetic sensations from a moving or pulsating part elevate this region’s likelihood of being recognized in conscious awareness and/or having greater power to influence viewing of inkblot anatomical structure.

Herman’s simplistic sensory feedback model still has some degree of relevance. It assists in understanding somatic symptoms arising from disease processes, which alter pain-transmitting neurons at the site of the pathology. It also has relevance to accounting for psychophysiologic symptoms arising from increased feedback secondary to stress induced body changes such as increased cardiovascular activity. The mid twentieth century Rorschach literature contains a number of studies relating anatomical responses to somatic symptoms (Ames et. al., 1954, Bohm, 1958, Levi, 1960, Weiss and Winnik, 1963, Barnes and Carnes 1971).

However, the relationship between projected anatomy responses and somatic preoccupation is a much more complex one than the literature indicates. For example, a clinical investigator might predict that when a stressed individual with resultant increased heart rate views cardiac imagery either in a tachistoscopic or somatic inkblot-viewing situation. In the former, it would be expected that recognition times would be shorter. In the later one might expect that more heart responses would be projected. However, in the pioneering studies the data were only partially consistent with these predictions (Cassell, 1965, 1972, Adamson and Varmose, 1976, Adamson, et al 1977). In sharp contrast some subjects who reported psychophysiologic cardiac symptoms perceptually inhibited heart imagery (Cassell, 1967, 1969). This introduced the need for a revised more complex body-mind-spirit model. In this, psychological factors of organ symbolism and affect linkage to a region’s mental representation represented additional influences. These could be powerful inhibition perceptual force sufficient to trump the physiological feedback factor.

This was observed in the present case history study. The frequency of pelvic Rorschach responses signified heightened projective awareness of this region to the interviewer. The pathological symbolism of “Bugs are attacking the pelvis” on Card X was interpreted to indicate the presence of unreported images of nonexistent cancer metastasizes. The fact that this was split off in her mind is reminiscent of Janet’s views of conversion reaction and “Hysteria”. This is consistent with the views of Endicott and Endicott (1963) that Rorschach anatomy responses may reflect unconscious somatic preoccupation.

It was noteworthy that when the anxiety-threat hierarchy was established she selected this last card as “Most upsetting”. Moreover once the triggering power of the order of administration had been used, then somatic imagery was projected onto the Rorschach stimuli on cards VIII, IV, V, III, IX, and I. In fact by this time a perceptual set for the pelvis had been established for all except Card VI, which was lowest in the rating scale.

Of those cards that evoked pelvic imagery, it is significant that card II was rated as next lowest in anxiety linkage. This included reference to the presenting physical symptom in her Conversion Disorder: “It looks like there is pain down there in the pelvic area with the red patch hanging in there. “Pain” was somehow substituted for disturbing affect linked to her mental picture of the pelvis. Clearly this was a major distress. This discomfort experienced by her in conscious awareness perceptually inhibited what in all likelihood was a greater threat, namely fear of cancer spread and death. While it is not unusual for people to deny death anxiety (Becker, 1973), her conversion of it to “severe pain” represented a disabling somatic symptom.

Most clinicians consider the use of inkblot testing such as the Rorschach, primarily for its diagnostic applications. In recent years, the widespread use of numerical scoring systems such as those developed by Klopfer and Exner, have tended to bypass the therapeutic value of Herman's inkblots in stimulating imagery for free association and content analysis. This failure partially relates to the fact that most modern therapists are not adequately trained in this approach for recalling painful memories and PTSD dreams. In the past psychoanalysts such as Roy Schafer did preliminary explorations involving Rorschach content analysis as an aide in treatment, Another reason for the original ten plates becoming relatively unused as an aide to therapy concerns the fact that the color-form configurations lack sufficient structure to routinely stimulate clinically relevant interview themes.

As an attempt to create visual stimuli more consistently capable of stimulating imagery for diagnostic and therapeutic purposes, the Somatic Inkblot Series (SIS) was envisioned in 1959. Work was initiated designing a new series of ambiguous yet partially structured designs, whose use been reviewed in this Journal and elsewhere. This presentation represents a longitudinal case history study of eight years comparing the diagnostic and therapeutic utility of inkblot images. It may also refresh the memories of clinicians concealing how projective stimuli can facilitate not only diagnosis, but also provide a powerful yet underutilized tool in the various current day psychological treatments.

A male college student age nineteen was selected for the case history study. He was referred by a psychiatrist and was plagued by incapacitating examination anxiety, when interviewed; he had major problems with stammering. Part of his developmental history, involved his having been placed at age seven by his parents in a boarding school in another city. At that time he experienced considerable abandonment feelings and severe homesickness. In addition, it was noted that until age twelve he suffered from enuresis.

As part of assessment and treatment plan development, he was given the Rorschach, SIS-I and SIS-video Images These procedures were completed initially in March 1991, then repeated in October 1991, then the third time in April 1992 and fourthly in February 1999. Repeating the visualization processes facilitated evaluating the clinical progress, while at the same time providing an aide for stimulating imagery for therapeutic discussion.

The longitudinal treatment plan involved insight oriented psychotherapy discussing his abandonment issues, content analysis with him concerning the significance of his inkblot responses, cognitive therapy and hypnotic relaxation. During the initial period of three months his psychiatrist provided him medication to assist in the control of his anxiety. Fortunately, he made impressive improvement from the biweekly psychological intervention.

After six sessions, since he was able to deal with his anxiety more effectively and consequently he was able to take and successfully pass examinations. The psychopharmacological approach was no longer necessary. However, therapeutic work on the stammering and interpersonal conflict issues continued at intervals over the observation period. These were on an "'if and when needed basis" for approximately seventy sessions over the eight years. As will be shown, eventually the latter sessions began to focus on stressful interpersonal issues not directly related to the original presenting problems.

Results of Inkblot Interviewing:

At the initial evaluation with the Rorschach, there were signs of both low productivity(R=12) and imaginative capacity suggestive of his anxiety problem. In spite of definite improvement in his clinical symptoms, the Rorschach responses did not reveal much change, nor did they stimulate therapeutically relevant percepts. The total number of Human content responses remained only 2 in all test sessions. Most Klopfer's scores were essentially no different with repeat testing. By contrast the Human content with the SIS-I was observed to increase over time. This matched his reduced examination anxiety and improved social skills. Initially he gave five human responses on the twenty inkblots and this number doubled on the last testing session. The quality of contents during 3rd and 4th testing improved, which can be observed in the tables, presented in this report. This was associated with a greater ability to communicate and interact with people. A few clinically significant responses on Rorschach, SIS-Video and SIS-I are shown below for understanding the pulling power of the test.

With the SIS-Video, there was a similar increase in his ability to recognize human content in the video presentations and their quality improved. For example, initially on image A1 he responded “lt looks like fungi or algae". Next he saw it as "A hand surrounded by fire", denoting the painful grief stemming from his unresolved abandonment issues. In the third session, he projected a response symbolizing his progress; 'A hand getting out, surrounded by plants". Finally, he saw it as "A hand of a person clapping!" This reflected his appreciation for the therapeutic assistance given over the years.

Next consideration will be given to illustrating how the discussion of his SIS-Video responses facilitated treatment, Firstly, in regard to the early abandonment issues, exploration with him of the following responses warrant comment:

A3 Initially he saw this as 'A human cell or roots of a plant that has been uprooted". Here the significance of the projection of the responses "human cell" symbolizes his traumatic loss at age seven when psychologically uprooted as denoted in the "plant uprooted". After his therapist repeatedly processed the family significance of this 518 imagery to him, he gradually began to resolve his abandonment issues. He learned to accept dependency on people as a necessary part of mature life. In working through his transference to the therapist, he acquired insight into the fact that loss and grief need not always follow trusting in close human relationships.

It was highly significant that he rated this symbolic material denoting as the "least liked" or most threatening imagery evoked by the 62 SIS-Video presentations. This demonstrates the critical importance of the therapist knowing developmental history concerning early losses and not attempting to do "blind interpretations". Lastly, in the final retest situation eight years later, he imagined seeing "a lovely flower with colorful roots", With growth in his self-confidence and esteem he could readily identify with a "lovely flower", The color signified his enhanced emotional state.

A14 Initially, he said that this represented "a picture on the wall" The next two responses correctly identified the anatomical structure embedded in the inkblot. This was consistent with his developing a more mature awareness and sensitivity to emotionally tinged body sensations, at the eighth year of therapy, he projected the response "Energy being sent from a person". This depicted his recognition that he could benefit from establishing interdependency relationships with nurturing people. Since had a religious support system, the additional value of spiritual meditating as a higher source of human "energy" was also discussed.

A18 He responded to this in the SIS-Video presentations as follows: "Smoke ring", "Lava, smoke, volcano, cloud from volcano and finally bright gases and lava ejected by volcano". His free associations to these responses in therapy immediately led to his emotional pain, low self-esteem, hurt and anger when originally psychologically abandoned in childhood the fact that he visualized the "gases" in brighter colors he realized symbolized his more positive self-image and hope.

To complicate interpretation, his therapist realized that some of his angry symbolism was stemming from new conflict with his parents. They recently had proposed a bride for him whom he considered unacceptable. Shortly before the fourth interview he had established a love relationship with a woman of his choice, Consistent with this he imagined SIS-Video Image A31 to represent "Two lovers kissing". Similarly, he envisioned B17 as "A heart beating on Valentine's day". Previously he had given the following responses: "volcano crater", 'heart", and "Bright flower with pedals". Also related to his evolving amorous interests, he visualized B22 as "A man sleeping and thinking of a woman he loves". This illustrates how the SIS may be used to follow maturing as an individual attempts to move beyond childhood fixations through new life passages. The Responses on Rorschach, SIS-I and SIS-II responses on initial testing and tree repeat testing are shown in tables 14, 15 and 16.

Table 14

Comparison of Rorschach Responses on 1st, 2nd 3rd and 4th Testing

Card #|1st Testing|2nd Testing|3rd Testing|4th Testing|

I|Bat|Bat|Bat|Bat|

II|Faces of two persons clapping like|Two persons clapping.|Two kids clapping.|Two persons clapping like.|

III|A person|Hand of an Animal|Frog-head|Two ladies dancing|

IV|Skin of an Animal|Animal like bat|Bat Flying|Bat |

V|Two deer's horns up|Bird like vulture flying|Bat flying|Bat Flying|

VI|Skin of a lion|Skin of a deer|Skin of an animal|Skin of an animal|

VII|Squirrel standing on a Rock|Two children playing|Two kids standing on something.|Two children playing|

VIII|Two animals climbing on a rock|Two animals like wolf going up|Two wolf going up.|Two animals climbing|

IX|Arial view of a valley|Rejected|Web's type|Two animals|

X|Various animals- Spider, Peacock, Rats|Various animals- Spider, Peacock, Rats.

|Various animals- Peacock, Spider, Fish

|Various animals- Spider, Peacock, Rats|

Table 15

Comparison of a Few Significant SIS-I Responses on 1st, 2nd 3rd and 4th Testing

SIS-I Images|1st Testing|2nd testing|3rd testing|4th Testing|

1|Two hens sitting|1.Two hens

2.head of a person |1.Two hens

2.head of a person|1.Two hens

2.head of a person|

5|1.Bat

2.Two children playing|As someone has been killed|Mother and two babies|Mother and two babies|

6|Two penguin playing|Two children playing|Two children joining hands and playing|Two children playing|

14|Insect with mouth|Insect like Beatles|Clown|Clown|

18|Face of ghost |1.Bat

2.Eyes, mouth face of some one|Man's face|Face of a person|

20|Rejected|Face of a person|Face of some thing |Face of a person|

Table 16

Comparison of a Few Significant SIS-Video Responses on 1st, 2nd 3rd and 4th Testing

SIS Images|1st Testing|2nd testing|3rd testing|4th Testing|

A 3|Plant uprooted.|Roots of a plant|Roots of a plant with branches|Lovely flower with colored root|

A 13|Looking like fungi algae|Hand surrounded by fire|Hand surrounded by plant|Hand of person clapping|

A14|Picture on a wall|Liver|Human Stomach|Energy being sent from a person|

A18|Smoke ring|Lava/Smoke Volcano|Cloud from Volcano|Bright gases ejected by Volcano|

A 21|Looking like a bat|Two small children with bat.|Two children playing around their mother|Hand of a person who is clapping|

A24|Rejected|Forest with tree|Pond in a Forest |Mother and baby|

A31|Faces of man and women|Man and Women|Man and women's face|Two lovers kissing|

B4|A girl seeing her face in a mirror|Two faces|Two male and female faces|Girl and boy sitting in a park|

B17|Looking like volcano crater|Heart beating|Bright flower with petals|Heart beating on valentine day|

B18|Rocket going up in war|Penis|Penis of a person|Graphic artist working on Epic|

B22|A person sleeping and thinking of some thing|Dead body soul going up|Person lying down and thinking he is dead and soul is going up|Man sleeping and thinking of Shen Ming|

B23|Depression created by a bomb|Spider with legs|Spider with legs|Bright color in a shop|

B28|A girl embracing her mother|Women embracing her child.|A girl clinging her mother|Mother and daughter|

B 31|Couples with children|Man and women with their children|Couple with their two children boy and girl|Happy family|

This longitudinal case history employing the Rorschach and two versions of the SIS perhaps may be best considered from an historical point of view. The use of inkblots in art and psychology predate Herman Rorschach by many years. What is of interest is the fact that even though there have been attempts to develop inkblots such as the work of Holtzman and others (references), somehow the great creativity inherent in Herman's blots have been forgotten by modem professionals who over utilize reductionism scoring in cult like training seminars. Most educated people associate the name Rorschach to the notion of inkblot testing when the subject is brought up. While scoring Systems have added immeasurably to diagnostic application, their very use has tended to obscure the clinical merit of using content analysis. Overlooking the rich symbolism of inkblot responses, such as those illustrated in Body Symbolism (Cassell, 1980), especially as they may readily lend themselves to the therapeutic approaches does the field of projective testing a great disservice. Although, many psychologists refer to the Rorschach data as resulting from "projective testing" this is a misnomer when standard scales are the sole source of data. What is even more of a tragedy for the field concerns the fact that there has been so little effort to improve in the design and presentation of the existing inkblots.

In this study it was shown how the rich imagery evoked by the SIS tended to make the Rorschach percepts pale in comparison. Ordinarily, ten relatively ambiguous blots cannot compare in projective pulling power with the SIS stimuli designed with embedded clinically relevant material. For example, the SIS is much more able to stimulate human percepts. In this case illustration, the clinical improvement with treatment over time was associated with a doubling in the number of human responses observed with the SIS-I but not the Rorschach

Apart from having 62 more visual stimuli for presentation, the SIS in the video version has more pulling power as a result of technology. It reduces test anxiety by combining floral relaxation for inducing hypnotic viewing with the opportunity for the viewer to write responses. The subject is alone, and like in hypnotic writing, does not have to hear what is reported Moreover, it is unnecessary to immediately share potentially threatening imagery with a professional person at the time the projective images and their disturbing emotions enter consciousness. When the subjects rates responses for those that are "least liked" the interviewer has an opportunity to evaluate their anxiety treat A busy clinician may simply get free associations to the most anxiety laden SIS image, without taking interview time with the others. For the college student under study, most threatening imagery provided very important information confirming the therapist's suspicion that early abandonment was a major stress. Of course, during the initial assessment, the youth had not yet been provided with this insight It was only after his therapist made this inkblot interpretation that he was able to begin to resolve this childhood loss. Giving associations in therapy sessions to the response to M "A human cell or roots of a plant uprooted" quickly led to the imagery's affect linkage and his long forgotten grief.

While longitudinal case histories such as this point the way for clinicians in the new millennium, it must be recognized that there are many obstacles to be overcome. This is particularly true in the United States where problems related to professionalism are formidable Psychoanalysts are rapidly becoming a vanishing breed. Even though they employ free association in interviews, most do not believe that they should include inkblot analysis in their treatment. Present day residency training programs for psychiatrists, since the era of psychopharmacology have become restricted by over adherence to the medical model. The concept of projection, whether it is onto inkblots, the individual's body, the therapist (i.e. transference), fantasy imagery and dream analysis are often relegated to outdated theoretical models. Many psychologists avoid projective testing because it is not readily quantifiable and to many suggests mysticism. Also because in the American private economic sector insurance companies are resisting paying for their work, many are experiencing drastic limitations in their practices. They are being rapidly replaced by less trained psychotherapeutic practitioners (e.g. social workers, psychiatric nurses, pastoral counselor's etc.) in test procedures. Moreover, psychologists in several states have convinced legislators to pass laws limiting test procedures only to licensed psychologists.

Whatever the professional discipline of the clinician, there should be a rich background of depth psychology, psychoanalysis and psycho-synthesis in interpreting the direct and symbolic meaning of projected responses. In fact, symbolic interpretation is the basis for deciphering the language of the unconscious. Although these issues of the therapist's socioeconomic status and power go far beyond the scope of this report, they must be considered challenges to be dealt with in the twenty-first century.

The Somatic Inkblot Series-II video (SIS-Video) was administered to a 40 year old woman who was suffering from depression. After viewing the SIS-Video she dreamt about an early life sled dog team. At the age of 3 years, she witnessed her 18 months old brother being killed by sled dog her limited verbal skill at the age of 3 years and the emotional unavailability of her parents, who themselves were grief stricken, she could never share this experience with anybody before the administration of this test. This suggests the power of somatic inkblot images not only as a diagnostic tool but also a therapeutic aid and a remarkable time machine.

It is generally recognized that when individuals view television programs containing vio­lence, this can have a profound mental effect. One involves the incorporation of violent images in their nighttime dreams. In a similar fashion, the viewing of SIS Video can give rise to threatening images, which stimulate dreams related to previously experienced trauma.

A case example follows to show how this had a positive emotionally cathartic effect. In addition, it had important cognitive therapeutic effects since the person relived the trauma through the eyes of an adult and could come to understand, as a result, that the previously held childhood guilt was irrational. The person in question is a 41-year-old woman who was referred by her psychotherapist for anti-depressant medication. She had significant neurovegative symptoms of depression. Since she was relatively stable, she was sent home with the SIS-Video and answer sheet. The instructions were to view the video before going to sleep, then the following morning, to record nighttime dreams in the answer booklet. Her next appointment was scheduled a week later.

Remarkably enough, the night after she viewed the video, she reported having a significant dream. She viewed an early life trauma that had been previously totally blocked from her memory. She recounted, at age three while looking out of her window, seeing her 18-month-old brother walking over to a neighbor’s sled dog team. She then witnessed the dogs viciously attack him. Because of her limited verbal skills at this age and emotional unavailability of her parents, who were grief stricken, she never had the opportunity to share this terrible experience with anyone. After viewing the SIS-Video, she, for the first time as an adult, remembered her horror. She experienced the repressed anger, guilt and grief about his tragic death.

The dream imagery involved visualizing her brother’s head and facial features in consciousness, with the horribly wounded body obscured in clouds. This information was communicated to her therapist.

When the results of the video were reviewed, she labeled the following three as the “Least Liked”:

A30: Was seen as the most threatening image. She saw “an evil skull in a cloud.” This response may be interpreted to directly reflect her dead brother. The fact that his body was not present in the initial dream reflected that the overall wounds were too painful for her to initially accept. It might be noted as time went on with therapy, a more complete image sequence of her brother’s death emerged. She was then able to grieve successfully and with cognitive therapy, correct her childhood erroneous belief of blaming herself.

B28: Was seen as the second most threatening image. She saw this as “A ghost-spooky.” It may be recalled that this image depicts a mother holding an infant. This was too threatening for her to accept in full conscious awareness. It may have reflected memories of seeing her mother holding her baby brother and childhood feelings experienced from also holding him.

B1: This was the third most threatening image. She saw this as “A fist.” She said that this made her feel even angrier. Therapeutic exploration of this took her back to long forgotten angry feelings about his death. In an irrational fashion, she had blamed herself for the terrible tragedy. Frequently, when something tragic happens in a family, children irrationally blame themselves.

Patient: I feel good about it. I feel open about it. I didn’t know what to expect when I fell asleep last night. I saw my little Bob.

Patient: It struck me as being something with “a lot of warmth and a lot of love”, and it really hit me that way when I saw it, and I really felt good about it.

Patient: Well, when I mentioned it before, I talked to you last; it is like I felt a lot of warmth and a lot of love for my husband. He probably feels a little overwhelmed by it all, but he’s handling it very well. He has been real supportive about it all, but as I get rid of the pain and grieve and understand, it’s just in everyday life you feel a lot of love for people and what’s going on around you, you just feel really good about it.

Patient: Not at all.

Patient: A family. It’s like togetherness. And I just see a lot of happiness and a lot of love there. It just struck me at that instant it just came to mind.

Patient: We had a lot of fun, from sledding to floating down rivers and looking at little baby ducks, everything you could possibly imagine, we did as a group, and it was really, really enjoyable. And after my little brother passed away, I sort of became my dad’s little girl. My sister became my mom’s little girl. And we kind of did things separate then.

Patient: Yeah. Yes I did, and um —, I really, um —I really did want that. And I think I really felt it when I was showing horse and I did it on my own, where they wouldn’t come to shows to watch me. And I wish they had been there as a group.

Patient: Oh, a person jogging, that’s just, um — that’s just how it struck me right away anyway. It almost looks like the person has a smile on his face. And that they’re real happy about it.

Patient: Um —, good health. Happiness. And probably getting out and doing something.

Dr. B: So that we know that fun in Alaska and exercise is a part of the treatment of depression.

Patient: Yes that is exactly correct.

Patient: In A30, to me, it was just a real, real evil skull in a cloud. And it represented death or the devil, and I didn’t like it at all. And it is something that we probably have to face.

Dr. B: And when we talked about this earlier, you told me some other things that were brought to mind, the devil and the pain.

Patient: With the experience I had been through before.

Patient: I had a friend who had died during childbirth, who was my closest friend. After she passed away, I felt like a separate entity was trying to take me over and where I lived and I went through a real battle in fighting this bad entity off and that I finally won.

Patient: Jolly.

Patient: She was a real kind hearted and gentleperson. A very loving person. We were born three months apart and grew up together.

Dr. B: So you were probably real close.

Patient: Probably closer to her than my own sister. We moved in together when we were single, after high school. We were always together. Almost - a real bond between us.

Patient: She got something like a hemorrhage, I believe. Her blood pressure shot up real high and she started bleeding in the head and they couldn’t stop the bleeding and she passed away.

Patient: Um, devastated. When I first heard the news, it was like took an inflated balloon and filled it with air and someone took out all the air at once. It was terrible-just a horrible feeling. Then I could also remember laying in bed that night and thinking of Jolly and at the same time I was crying and crying about her and all of a sudden my tears stopped and I really, really felt that God was there holding and comforting me for a while. And I never felt such peace or comfort in my whole life. It was wonderful.

Patient: A long time.

Patient: She would come to me and she was still on the pregnant side and she would say, “I’m okay! Not to worry, but I’m fine.” She did that several times.

Patient: Happy that I saw her. But her death affected me so much that for years afterwards if I was driving down the road and I thought about Jolly, tears would come to my eyes. But it wasn’t until when Ann (her psychotherapist) had me write a goodbye letter to her I was able to… I felt then maybe I could let go of her.

Patient: I remembered all the fun times we had together, and how close we were together, and how we enjoyed and that I knew it was time for me to let go off her, but I would always love her.

Patient: Yes it did. At that time I didn’t understand it, but it made…having a tubular (where you have the tubes tied). I had that done and I thought I was having some problems — birth control pills that I’ve been on for quite a few years and the doctor thought I was having problems with them. So we decided to do this. But later, since I had it done about four months after she passed away and I had surgery to have the reversal done. And it wasn’t until this year that I actually realized that probably the real reason was because of Jolly’s death.

Patient: Probably the fear of maybe because of Jolly died in childbirth and that it was so sudden — maybe, — maybe it was my own fear of it happening to me or maybe it was — maybe because I didn’t think it was fair that she should die during childbirth.

Patient: Yes.

Patient: I’ve decided, naturally, both my husband and I talked about it, and we have come to terms with that, should it happen, that if we were blessed with it, it was meant to be. Because as far being checked, everything is in working order.

Patient: Yeah.

Patient: A ghost. And it struck me as not being as being good. It struck me as being more on the bad side.

Sherry: I think of Bob’s death and I think of Jolly’s death.

Patient: Depression, everything being more on the gray side.

Patient: Um — which one? Oh, anger. And I think I felt angry at Bob for leaving us like that. And maybe — and may be blaming myself.

Patient: I couldn’t understand why they had attacked him. I could never understand that.

Patient: I remember my mother finding Bob and he was still alive and she picked him up and put him in the car. And I went to the driver’s side of the door and I asked if I could go. She said “No!” She was frantic — I mean she was absolutely frantic! But I couldn’t — I couldn’t tell you what I saw on the seat. Even though Bob was lying there on the seat I couldn’t tell you what I saw.

Patient: Yeah. Yes, that’s for sure. And I definitely… but after my dream last night and actually seeing Bob with blonde hair and blue eyes — and actually seeing him, I feel relieved — real relieved about it.

Patient: Well, I dreamt that, my dream started off with men and women in a kind of army/military type situation and then I, um, dreamed of a scalpel (which Bob did have surgery on him before he passed away — before he died they did perform surgery on him). And then it was kind of cloudy and foggy and then the clouds parted, and there was Bob and he was lying on his stomach. I wouldn’t say he was smiling, but he wasn’t sad. He just looked content. And he was just looking at me, and I felt very frightened if what I saw, I didn’t expect that to happen. It woke me up and I can remember looking at the clock and it was 2:05 A.M. and I was really, really startled by it. Um.

Patient: Because I actually saw him. It was seeing Bob. And maybe because I didn’t see beyond the head and shoulders, I didn’t see the rest of the body.

Patient: Because that is the part of the body that was injured. I think that was what it was. I think that was why I probably woke myself up.

Dr. B: Because you didn’t want to see the horror, which you saw as a little girl and this represses that.

Patient: Right, exactly.

Patient: I got up and I went to bed. And I felt really… I cried for a little bit, but I didn’t cry hard, but I did cry for a while about it and thinking about seeing Jimmy. And I felt the best thing for me to do is I sat down and I prayed to God. And I asked God, what do you want me to see or what do you want me to feel? I will leave it in your hands and then I will see it. And I left it up to Him. I then went back to sleep and I had two dreams after that. One was of a floatplane taking off a lake, but the floats fell off the plane and it was so it was no big deal to anybody and the other one was of … (interrupted).

Patient: It brought back that the plane could not land; it could not land again when the floats fell off.

Patient: That it could not come back to Earth.

Patient: Bob.

Patient: That he cannot come back to Earth! That he is gone forever.

Patient: Um, that it is God’s way of telling me that he was probably fine.

Patient: Yes I do.

Patient: I really do feel that I will see Bob again, and my friend Jolly.

Patient: Yes.

Patient: There was a little choo choo train with an old steam engine that came flying through the air over the lake after the plane. And — and it was a bright gold train, a little choo choo train, with a green trim. And I was looking, and nobody thought it was a big deal. It was okay that it was flying through the air.

Patient: It was kind of funny. I thought it must not be a big deal if no one else thought it was a big deal, but it was just okay.

Patient: That again — that it was okay, and, um, no matter how odd something is, sometimes it is all right, or the circumstances — that we just have to realize that. So, it is hard.

Dr. B: Yes, it is hard. Yes, it is hard. It has a wonderful that you are getting in touch with some of these feelings and freeing yourself up for love now. That it would be even more of a wonderful miracle if you and your husband could connect with a baby.

Patient: Yes.

Dr. B: I was wondering if we take a few moments now and go through the whole series of images. I do not want to tire you out, but if you could just look at each image and tell us what you see, starting with image A1 and go right through it, please.

Patient: A1 hit me as two bunny rabbits. And they look like happy bunny rabbits.

Patient: Um — other than that we had little rabbits when I was growing up. We usually had rabbits running and they were just pets. And I really enjoyed them.

Dr. B: So this goes back to a happy childhood theme.

Patient: Yeah, oh yeah.

Dr. B: Okay, A2.

Patient: Is a squirrel with a tail which… when I looked at this image on paper it looked a little different than it did on film. It reminded me of a squirrel; then again, there were lots of squirrels running around. And there used to be lots of them and they were fun to watch.

A3: Flowers floating on a pond. That reminded me of a lot of Lily pads and stuff floating around on the pond. I always thought that they were really pretty and I enjoyed them.

Dr. B: Yes, Alaska is really beautiful.

Patient: Oh yeah. And image A4. It was a person on the left with his hands up and on the right it looked like a bus: part of a bus. And, — um, I’m not sure why I saw that, but it was what came to mind when I saw this particular image.

A5: I thought it was kind of comical. It was kind of cute. It had a Moose’s head at the top, a heart in the middle, and a person’s body at the bottom. And I thought that was some kind of comical thing.

A6: Was a pumpkin that had two legs and a little teddy bear I saw — just sitting there.

A7: Looked like a tomato and then a dancing person.

Dr. B: Okay.

A9: Two people. To me it looked like they were dancing a square dance and then, when you look at it again it could be two duck heads.

Patient: Yes it is.

A10: Reminded me of, when I first looked at it, like parts of two pansies of the flower petals.

A11: I couldn’t come up with anything. Nothing came to my mind at all.

A12: Clowns face with a hat on. And to me, the face was in the middle with the hat coming over the top.

A13: A hand and then with people around it. It looked like little people to me — here. And there were people around the hand.

A14: Was smoke coming out of a hole, is what it reminded me of.

A15: Was a pelican in a dive. It looked like a pelican doing a dive.

A16: Were two birds kissing.

A17: Was a heart inside a rib cage, is what it looked like to me. Or it looked like it could be two horses’ heads and a heart.

A18: Was a heart with a bunny rabbit and it looked like the back of a bunny rabbit with his ears up.

A19: Was an intestine, is what it looked like.

A20: Looked like two kidneys.

A21: Looked like a bird. Because the colors in the picture it brought forms to, it looked like two little pigs with a bird. It was kind of cute.

A22: That just hit me as a lobster because of the shape of it.

A23: Was a candlestick holder.

A24: That reminded me of people in the forest — probably because of the darkness of the image.

A25: Was a mask.

A26: Reminded me of a womb, of a baby in a womb.

Patient: I felt good and I felt a little sad.

Patient: Birth. Um - something new happening inside a person.

Patient: Is that I do not have one.

Dr. B: Yet.

Patient: Yet (laughs - anticipation, hope).

A27: Reminded me of a little yellow chicken in the film. I’m not sure how I came up with that after looking at it here (laughs).

A28: Reminded me of a person’s torso.

A29: Looked like a volcano eruption to me.

Dr. B: Well, we did have a volcano eruption going off here recently (laughs).

Patient: Yeah, we sure did.

Patient: Yeah it did.

Patient: I was wondering if it was going to go really hard this time. You probably remembered when it erupted, in probably the fifties. And we were covered with dust and we had to stay in our houses.

Patient: Yes, real quick (smiling).

A30: Was a “Skull. An evil skull in a cloud.” I just didn’t feel good about this picture at all.

Dr. B: Yes, we talked about that.

A31: Was “two people faces with their brains –“because in the film it looked to me like their face and brain were bright colors in the film.

B1: Was a “fist” we talked about.

B2: I could not come up with anything on that at all.

B3: Reminded me of a “cow’s skull—” of the old skull as you would see in the desert.

Dr. B: You’re going to have more fun as you process this grief.

Patient: Oh yeah, a lot more fun (smiles).

Dr. B: Yes.

B6: Reminded me of a “flower or a sea anemone”, which I think were real pretty floating around.

B7: “A sting ray fish.” That could be because when I was in Florida I got to pet one as it swam by (laughs).

B8: Reminded me of a marble in the film and here it looks like part of a person’s face or nose.

B9: It looked like two kidneys with a hand holding them at the top.

B10: Reminded me of an owl.

B11: Looked like flags waving in the wind.

B12: Was a tree.

B13: I could not come up with anything on that one at all.

B14: It looked a face in a bottle, and it was very faint.

Patient: No, not that I could remember. B16 reminded me of an African with a mask on.

B18: Was the back of a person. Looked like a person just standing there.

B19: A starfish with a couple of hearts in it, or a jellyfish.

B20: A half moon with a cloud.

B21: Reminded me of Mr. Potato Head, which was the game we used to play when we were kids (laughs). And you got to detach all the parts.

Dr. B: It sounds like you had a lot of fun when you were a little girl.

Patient: Oh yes, we did.

B22: Reminded me of a person lying down with bubbles coming out of him.

Patient: Yes, of Bob dying is what it brings to mind.

Patient: Sad, very sad about it.

Patient: I did (laughs).

Patient: I felt really relieved. It is — I don’t know, its funny how you feel healed, or start to heal.

B23: That reminded me of ribs, of people’s ribs.

B24: I couldn’t come up with anything on that.

B25: Looked like hands holding a Christmas ornament.

B26: Was like a shirt and a pair of pants.

B27: Was two people dancing.

B28: Was the Ghost.

B29: Was a person jogging.

B30: Looked like two people’s ears.

B31: The last one was a family, which… that imagery hit me really strong.

Patient: Togetherness and happiness.

Dr. B: Yes.

Patient: Yes, very, very much so.

Dr. B: Thank you.

Patient: (Smiles).

It can be concluded that the SIS-Video took the patient back in time and stimulated her through dreams of her 18 months old brother being killed by a sled dog team. Processing her grief and anger helped her. SIS-Video has been found to be a powerful test helping in hearing the inner cry of the patient and relieving trauma.

Stimulus Plate SIT-17: Pelvic & Anatomical Localization

Miss X, 27 years, unmarried, Law Graduate, practicing as attorney, belonging to high middle class family, had history of sex abuse at the age of 4 years by a 19 years boy, physical relationship with an aged family friend, history of feeling depressed, wish to leave the family and conflicting parental relationship was given Somatic Inkblot Series Video for understanding the personality and therapeutic intervention. Interpretation of a few responses found to be quite relevant has been given for understanding the psychology of the case.

A1: She saw “A man who looks healthy and majestic but pretty empty inside” is a direct projection of how she feels empty inside although she looks normal and healthy on the outside. The fact is that she conjures up images if a man rather than of women may reflect her sexual identification partially identified with that of her perpetuator my.

A3: Many people in viewing on this image introduce spiritual connotation with this image. Here she directly projects her feeling of wanting to be free of her past traumatic memories and inner trauma be seeing “My soul when will it become free”.

A5: She viewed “A Lady who is all heart celebrating alone” is direct projection of same sex identification to the human form. She focuses on the heart because she is introspective and socially withdrawn as a result of her pain and depression. It may probably also represent a projection of her mother’s image that is critical and non-supporting. Her depression is abnormally high and she has given lot many responses depicting depression.

A6: “A sad teddy bear” brings back the theme of sadness or depression almost in a perseveratory fashion. In addition the response has repressive features. She totally avoids reference to the human gestalt and focuses instead in a childlike fashion in a teddy dear.

A10: ‘Blind Woman” is the projection of her psychological blindness associated with her repressing images of her past sexual abuse. She also comments that she is getting impatient and needs therapeutic resolution for her long standing childhood conflict.

A11: She viewed ‘A needle through the heart-I want to weep but I won’t” This is a direct projection of an emotional pain and depression, the fact that she conjures up the image of a needle penetrating the heart symbolizes her past sexual penetration and body boundary violation. In commenting on this horrible response, she for the first time acknowledges to the examiner her depression and need for emotional catharsis as well as her inability to do so as without therapeutic assessment.

A12: She viewed “can you hear me with your ears and listen with your heart”. With this question she directly asks the interviewer if she will be heard with empathy and compassion. Previous attempt to share her pain as a child felt on the deaf ear of the parents.

A13: She saw “A window hazy with fog with the center clear, a hand out stretched asking me to wait. May be I should give up” Here she continues the theme of her own reluctance to weep and share her pain with the therapist. She has learned from the failure of past attempt to share, which were met with frustration, and further hurt that the process of attempting to communicate may itself lead to further hurt and rejection.

A11: The hand symbolizes that part of herself that “I won’t, will not allow herself to trust the therapy process. To remove this resistance in therapy it would be necessary to interpret the symbolic significant of this response in terms of transference. Lastly the reference to ‘giving up” continues the depressive feelings of her helpless.

A14: She saw “A dry flower” on this image. Here, rather than recognizing the anatomical structure, she projects herself image as being dead inside.

A18: She viewed “A man hanging upside down with smoke bellowing out of his head and waiting to fall through the dark circle into a hole”. Many individuals see anatomical contents here such as the heart or image of sexual intercourse. Because of her sexual trauma and resultant pelvic anxiety she totally avoided reference of somatic structure in the video image. The defensive material projected symbolizes of her severe depressive mood and latent death wishes. At times she fantasizes running away from her home and escaping from her problems.

A23: She saw “Looking like a deadly ardroid, resembles a creepy centipede (scary feeling)” Here the response is remarkable because of her failure to correctly identify somatic structure, which is so clearly depicts spinal column. There are two possible determinants of somatic repression, one relates to her past medical history of having fallen 4 year earlier injuring her tail bone and causing considerable pain. The other relate to phallic connotation of this particular image. While both hypotheses can lead to heightened body anxiety, symbolic analysis of her defensive imagery suggests that the later determinant is more noticeable that she saw a deadly ardroid resembling creepy centipedes which is highly threatening to her.

Remember that previously in responding to image the needle had threatening phallic connotation. A little girl violated by penal penetration will always carry such negative association to phallic imagery.

A 31: On image A31 she viewed “A beautiful women looking at her hazy reflection. She is not sad yet contemplative (feeling confused)”. Here she avoids reference to central content in A31, which pictorially depicts a man and woman is very close interaction, because this material is highly threatening to her due to her past experience with her male perpetuator. The normative content is totally repressed. She defenses against this structure by substituting image symbolizing herself in therapy looking at her psychological defense mechanism of denial. The introduction of the idea that the woman is confused symbolized her own confusion and cognitive disarray.

B31: “Two people sitting inside a womb overlooking alter of fire”. Here fire signifies life (feeling of wonder).

B3: “Two people inside the womb continue the regressive theme previously noted on A6, the fire denotes her emotional pain. In this essence rather than associating depressive aspects she introduces the concept of life and wonder. This was positive prognostic implication to therapy, and needs to be interpreted to her context. There is hopeful recovery if she is willing to share her pain during therapy.

B6: She saw “A half statue girdle downwards with some infection around the girdle (feeling of depression)” on image B6. Here she partially picks up the correct anatomical structure referring to the lower abdomen and thigh. However, because of her trauma to related pelvic anxiety she defends against the specific somatic content by seeing a more abstract image “i.e. statue girdle”. Here it is noteworthy that she projects a pathological anatomical response. “Infection” symbolizes her own inhered genitalia. The facts that this image accentuates her feeling of depression in responding to the Image indicated that she is grieving the loss of her virginity and body boundary intactness. The assault on a child’s body id not just injurious in a sexual way but when a perpetuator is a close family friend, the overall ego becomes distorted and confused just like she indicated on A31. The other explanation could be her repeated infection in her pelvic region for which she has taken treatment.

B12: She viewed “A parrot hanging upside down trying to fly away”. Here again she totally represses the real structure of the image, which dents some man’s facial area and nose. Substituting image of a parrot neutralizes the threat in this image. The fact that the bird is seeing upside down trying to fly away directory symbolizes the childhood feeling of vulnerability and helplessness to avoid her perpetuator.

B16: She saw “The centipede is back again. I hate centipede (feeling of filth and dread”) on image B16. The significance of this response is previously reviewed with A23.

B28: She viewed “A person hugging a white colored pet”. Most individuals who have had experience of positive nurturing mother will see as a woman holding the child. Here she defends against by avoiding reference to the maternal and female connotation of the adult figures seeing only a “Person”. Similarly she avoids reference of the child introducing the image of a pet. In spite of this, it should be recognized that of an image which was loving and affectionate. Frequently when child has not received maternal love, they will turn to pets to meet the; need for aggression. Such individuals with other inkblot test such as the Rorschach test and the Holtzman Test give higher number of animal response than the human response.

B30: She saw once again “Two ears-can you hear me?” on 30B, Here like in A12, she directly asks the therapist if her inner cry will be heard and responded to therapeutic alliance and that she is given reassurance that unlike the past when no one has heard her she will be heard with empathy and compassion now. In this sense her cry will be heard and she will have the helpful therapeutic relationship. Many male therapists because of trust issue prefer to refer such traumatized female patients to a female therapist.

Here we have presented two cases of clinical interest. Although the subject of both cases is females it is important to point out that the problem of inner cry is not only males or females but human beings in general. It is not limited to any particular part of the world, society or culture but is universal in nature. The responses to SIS have been successful in identifying the inner cry of the individual, which itself is the first step of therapeutic intervention.

It is important to remember that the projective tests do not have so called objective procedure of interpretation. It is the clinician’s acumen, which is necessary to interpret a protocol. In the first case study, it was a denial of the problem initially, but through SIS images and on subsequent enquiry it revealed the roots of the problems, whereas in the second case study, it was the obvious percepts to unstructured stimuli. Rorschach test was tried in the first case but could not reveal much. It could be due to the fact that Somatic Inkblot Test is based on the theory of body imagery whereas; Rorschach is largely based on general perception.

Stimulus Plate SIT-24: Living Images / Female Somatic Dynamic

Clinical Case Illustrations:

Three clinical case histories will be presented to illustrate the use of Living Images in women who met the criteria for PTSD as outlined in the Diagnostic and Statistical Manual of Mental Disorders, 4th ed(DSM-IV) (The American Psychiatric Association, 1994).

The first involves a single woman who was repeatedly raped as a teenager by a relative in his thirties. She sustained permanent physical damage to her reproductive structures. As a result, she was markedly concerned about whether or not she would be able to have children. Her fears surrounding her damaged body image (BI) were reflected in her focus on Image 37 as "A hole in the uterus". It is evident how such a response could provide a useful starting point to explore her abuse issues as well as her ongoing fears about sterility.

The second case involves a middle-aged woman who was temporarily residing in a treatment facility for abused women. She had a long history of the following: repetitive abusive relationships with men, PTSD, Major Depression and Chemical Dependency. The most recent assault had occurred three months prior to viewing Living Images, after she had moved in with a man who abused her psychologically, physically and sexually. Poorly educated, with limited intellectual and verbal skills, she had considerable difficulty communicating about her traumatic experiences in therapeutic interviews.

By contrast, in the projective viewing situation, she was more open. However, she was still sufficiently guarded that she could only give very brief responses to the test images. These were easily interpretable with simple content analysis. Her early features of Dissociative Personality Disorder resulting from her long traumatic history were reflected in her projecting these onto Inkblot 10 as "split personality".

Her psychological numbing and isolation from her inner emotions was projected to Inkblot 11 as "detachment". In viewing #33, she gave the pathological anatomical response "punch in the eye", directly denoting previous facial injuries. Horrible images of repeated sexual assault were projected in the response "A rape...I feel sad".

One does not have to be a trained in projective testing and symbolic interpretation to understand the clinical significance of such PTSD inkblot responses. Playback of these specific images as television stimuli in group psychotherapy with other abused women provides a useful follow up therapy technique.

The third case was selected to illustrate more sophisticated phenomenological analytic approaches. The victim was a middle-aged woman who, a few days before evaluation, had been savagely raped. She sought therapy suffering from classical features of severe PTSD. She was an intelligent woman, who, years earlier, had worked as a teacher, prior to immigrating to the United States. Past history revealed that a few years earlier, a so-called family friend had sexually assaulted her. She never reported or sought treatment for this earlier trauma.

Being a former teacher, she appreciated the need to develop educational television programs and consented to review her original responses to 'Living Images". The teaching tape was first completed in English, with one of the authors as professional interviewer. Then, the detailed inquiry was repeated in the television studio as a woman interviewer questioned her in her native language. After briefly reviewing further conceptual background for Living Images, the transcript of the English interview will be presented:

Conceptual Background:

It is generally recognized that any form of art partially represents a direct projection of the artist's own psyche and past imagery. For art forms designed to accurately depict physical reality, what is projected onto external physical reality is ordinarily only minimal. For more abstract artistic works, the creator's subjective inner fantasy life and dream images can alter the production. Visual hallucinations, such as those induced by hallucinogenic drugs or illness, can also influence the work of creative individuals. For example, some neurologists have suggested that Vincent Van Gogh suffered from a form of epilepsy, creating the visual effects evident in his pictures.

Similar projective principles operate in those making inkblots for psychological use. In the historical literature on inkblots, one factor which has not been properly addressed concerns the sex of the artist. For creating the original SIS, the services of five artists were utilized. Three were men and three were women (Blots 1A, 2A, 3A,31A,1B, 2B, 3B, 4B,17B, 25B, 28B, 29B, and 31B).

Extensive clinical experience with this series in traumatized women suggested that stress related to sexuality and reproduction represent important unresolved areas of trauma. For example, in visually processing SIS image 27B (stimulating fetus imagery), many women released their previously unexpressed anguish regarding past miscarriages (Cassell & Dubey, 1996). After resolving this unresolved emotional pain and suffering, they frequently complained in psychotherapy sessions about their past poor psychological care by obstetrical care providers and their failure to have an appropriate referral for counseling. Many had been clinically dismissed with simple statements such as "a lot of women lose babies, you can always try to get pregnant again". This professional aversion of many medical practitioners to recognize the need to grieve failed to appreciate the highly stressful nature of such losses.

It was anticipated that the Living Images would facilitate the exploration of aspects of feminine consciousness. It is hoped that the series may lead to new therapeutic avenues. Like the original SIS, it was designed in both video and booklet versions. For the purpose of test-retest comparison, two images (17B and 31B) were repeated. To provide visual structure to stimulate imagery denoting "splitting", such as occurs with severe trauma in the dissociative disorders; the artists designed some of the human content in the inkblots with split figures. Lastly, the projective procedure was named, avoiding feminist

connotations, as a partial disguise to its primary use for women. It was anticipated that it might also have utility in the assessment of other family members traumatized by stressful issues related to a woman's reproduction cycle, including males.

Interview Following Viewing of Living Images by Case III:

Interviewer (I): “We are going to put the picture from the video, Living Images, that you rated most threatening on the television screen. Please tell us what you see and feel in looking at that again today."

Patient (P): "Some kind of evil looking at everybody, maybe, special to me, is some kind of the most people have inside. I think some of us, this some evil, like you know it's got a mean face.

P: "Yes".

P : "Yes, I was working, working a hotel and I supposed to check a room, a empty room to see if the status is clean or no, and it's terrible, and but I saw this guy before and I know on another floor, I go to tell the leader Phillips another floor and I saw this guy crossing and I said good evening like we need supposed to doing and I take the elevator, the guest elevator to the other floor and I go inside the room and when I'm coming out this guy coming from the elevator and he jumped on me and stabbed my neck and pushed me inside the room and he not say nothing- he don't know me, he no say anything, he start to close and close and he go in back me and have my hand tie my hand and he start to get the other hand to check my clothes and go inside me- with my hand I scratched his face, I feel that his eyes and I scratch it and he tried to bite me and I pulled his hair, but he put the two hands together and I don't know, he closed my neck completely, he no leave me chance to talk, he don't know me".

P: "I cannot give you the color but they looking at me straight and he put these lips like animal like fear of like filthy little teeth pretty mean, but he no know me, he never know what I maybe I am old or what, he was very good looking guy, strong, strong make me feel very scare, I think if he's jumping again and again and again and before night I think that he's coming maybe person is closest is there.

I: "I would like to continue the video and move on to some other images that you had seen. Do you remember what you saw when you saw when you looked at this particular image? “(Showing Image).

P: "Yea".

P: "I have many dreams now…last night I had another one and another one. I was somewhere anytime I saw him jumping me - any door was open - any man I cleaning in some moments changed and be that guy.

P: "Sad, sad."

I: "Yes."

I: "Yes."

I: "OK."

headache last night and sway."

P: "Yes."

Interviewer's Comments:

Perhaps it might be helpful to consider some additional information about the interview. Initially, it began with a detailed inquiry of responses to her favorite image which was seen to represent “a happy family". Starting with this one reduced test anxiety and the associated stress of being on camera in a commercial television studio. Her associations to the "happy family" image led her immediately to speak about a meaningful love relationship with her father. This provided important information concerning her internalized positive image of men. Without this developmental background, it would not have been possible for a male interviewer to effectively build rapport in an interview. This trust was enlarged upon in the second portion of the television studio interview by repeating the detailed enquiry with a female interviewer, speaking her native tongue.

The emotional quality of the interview changed dramatically when the detailed enquiry focused on obtaining free associations to the most threatening inkblot. After the initial viewing in the clinic, she had indicated that this inkblot reminded her of her perpetrator and her PTSD dreams. Her associations illustrate the close parallel between the inkblot imagery (Inkblot Imagery or "II"), her conscious recollections of the visual reality at the time of the trauma (Memory Images or "MI"), and the terrible images in her dreams (Dream Imagery or "DI").

Apart from the emotional discomfort related to the MI and DI, that she was greatly distressed by the perception that people didn't listen to her complaints of suffering. Frequently, rape victims are further traumatized by lack of understanding in law enforcement officials or others who should be more supportive.

It may be recollected as well, that images of the perpetrator's evil eyes haunted her. The changes in herown body image (BI) were also dramatic. These were reflected in her vivid art work illustrating "blood on her hand" and" shame". The overall change in her BI was that she felt "very dirty" and obsessively tried to wash the olfactory sensations away. In the second drawing, the emphasis on eyes signified her paranoid fears that people "look at" her without sufficient emotional support or understanding. The shame is augmented by those who erroneously imply that such a victim "enjoyed" the sexual assault.

Next, consideration might be given to the phenomenological observation that the inkblots were able to assist her in communicating about her positive sense of spirituality within her BI. This was symbolized in her reference to the "light" emanating from within. The video also enabled the interviewer to begin cognitive therapy correcting her guilty thinking that she had "evil within", because of her aggressive attempts to defend herself.

The final blots more closely include anatomical structure denoting the female reproductive system, enabling the expression of her sadness concerning loss in this respect. Similarly, they facilitated her communication about the changes in her BI secondary to the pelvic pain experienced during the violent assault.

Finally this projective interview permitted an examination of flashback imagery ("FI") from an assault years earlier. The in depth treatment plan involved the therapeutic processing both of her recent PTSD sexual assault memories and the long term ones.

Discussion:

Case histories were presented illustrating how women suffering from PTSD secondary to sexual assault were interviewed with the aide of Living Images. This video projective technique accessed traumatic memories and painful emotions. It provided a therapeutic opportunity for the expression of the terrifying DI and FI imagery. When combined with art therapy, Living Images was able to effectively compliment both the assessment and therapeutic processes. It facilitated cathartic emotional release, as well as clarifying disturbed imagery, body perceptual problems, cognitive confusion, etc.

Apart from the above applications, much quantitative research work needs to be done - especially in association with established multi-method assessment procedures. For example, studies needs to be completed by behavioral scientists in the development of psychometric scales for statistical studies. As a starting point, these could address the issue of "diagnostic utility" - the extent to which a particular test index can accurately predict that a person belongs to or does not belong to a specified category (Van der Kolk, et al, 1996). The video system needs to be compared with existing structured and semi structured diagnostic interviews, such as the Structured Clinical Interview for DSM-III-R (Spitzer et al, 1990), The Structured Interview for PTSD (Davidson, Smith, and Kudler, 1989), The PTSD Interview (Watson et al, 1991). The same applies to the need to correlate it with self-report PTSD checklists such as The PTSD Checklist (Weathers et al, 1993), the PTSD Symptom Scale Self-Report (Foa et al, 1993), the Dutch PTSD scale (Hovens et al, 1992), etc. Until such comparisons are made, it is essential to be prudent regarding the video technique's overall diagnostic validity.

In looking to the future, brief consideration might be given concerning how such inkblot procedures may be aides to therapy and clinical investigation. Of the multitude of modern therapy techniques, this approach is particularly relevant in the use of EMDR in treating PTSD. This procedure was originally developed by Shapiro (Shapiro, 1995).It is more based upon body oriented techniques and sharply differs from most traditional language dependant therapies. EMDR instructions ask the victim to focus on the body and conjure up traumatic images, while the therapist alters sensory input by guiding eye movements and stimulating sensory input (e.g. through touch, sound stimulation etc.).

Investigators in this field have recently accumulated a body of data which may enrich existing inkblot interpretation theory. These stem from both animal stress studies and human research with victims of PTSD. In the review of the extensive literature on the effects of stress on experimental animals, it has been observed by Van der Kolk et al (1996) in their insightful book, Traumatic Stress that traumatic sensations may then be revived, not in the distorted fashion of ordinary recall, affect states, somatic sensations, or visual images ('nightmares' or' flashbacks') that are timeless and unmodified by subsequent experience. The concept of indelible sub cortical emotional responses, held in check to varying degrees by cortical and septo-hippocampal activity, has led to the speculation that delayed onset PTSD may be the expression of sub cortically mediated emotional responses that escape cortical (and possibly hippocampal) inhibitory control (Van der Kolk and Van der Hart, 1991; Pitman et al., 1999; Charney et.al, 1993).

The related human neurologic studies have uncovered specific abnormalities of the limbic system in PTSD. For example, clinical investigations have found that people with PTSD have decreased hippocampal volume - part of the brain concerned with memory.

Particularly relevant to the first clinical case presented above is a study by Stein et al (1997) indicating a 7% reduction in hippocampus volume in women who had repeated childhood sexual abuse. In a different part of their book, Traumatic Stress, the above authors summarized their original experiments concerning the activation of PTSD symptoms by reading transcripts of the original trauma, while measuring with positron-emission tomography. They found that "subject’s demonstrated heightened activity only in the right hemisphere - in the paralimbic belt, parts of the limbic system connected to the amygdala, the insular cortex, the posterior orbital-frontal cortex, the anterior cingulate cortex and the anterior temporal cortex. Activation of these structures was accompanied by activation in the right visual cortex, reflecting the visual experience of their traumas. Significant ( by its absence) was the observation that Brocas's area, the part of the left hemisphere responsible for translating personal experiences into communicable language, showed a significant decrease in oxygen utilization during the exposure to traumatic reminders. This probably means that during activation of a traumatic memory, the brain is "having" its experience. The person may feel, see or hear the sensory elements of the traumatic experience. He or she may be physiologically prevented from translating this experience into communicable language. When PTSD victims are having their traumatic recall, they may suffer from speechless terror in which they may be, literally, out of touch with their feelings. These impressions are consistent with LeDoux's (1997) hypothesis that emotional memories can be established without any conscious evaluation of incoming information by the neocortex, and that a high degree of activation of the amygdala and related structures can facilitate the generation of emotional responses based upon fragments of information, rather than full- blown perceptions of objects and events to a particular stimuli." These observations may have relevance to those who employ projective inkblot assessment. Herman Rorschach proposed that certain projected anatomical responses in his inkblot series reflected the subject's awareness of kinesthetic sensations. Consistent with this thesis, two of the SIS inkblots (A17 and A 18) were originally designed with heart-like visual connotations. This was done to enable the study of the psychophysiologic relationship between cardiac consciousness and sensory feedback of cardiovascular arousal (Cassell, 1969). It was expected that stress- induced, increased heart rate would lead to increased sensory feedback from the cardiac region, and therefore, a tendency to project increased numbers of anatomical responses denoting cardiac consciousness. In one early project (as expected), it was found that individuals suffering from cardiac symptoms (e.g. palpitations, pain, etc.) projected an increased number of heart responses. By contrast, there was another group who were symptomatically highly aware of their hearts, yet who avoided such cardiac connotations in the newly created somatic inkblots. Originally, Repression-sensitization theory (Byrne, 1971) was considered relevant in attempting to explain these paradoxical findings.

The insights concerning mind-body relationships reviewed in Book (Van der Kolk et al,1996) would appear to add a central nervous system missing link to the understanding of such paradoxical mind-body relationships. It now seems pertinent to hypothesize that some projected anatomical responses may reflect right brain activity in the limbic system associated with "brain pictures", occurring at moments of previous stress. Given such conceptualizations and those of others, it is understandable how these may tend to be far removed from left brain cognitive function and consequently, distant from conscious awareness.

There is much clinical evidence to indicate that inkblots can access right brain memories beyond the realm of cognition and language. Content analysis of projected imagery frequently symbolizes a particular trauma, but the victim cannot explain or recall how it relates to long forgotten past traumatic episodes. An example observed a number of years ago by one of the authors (Cassell, 1980) involves a gynecological patient suffering from cancer of the cervix. She was sufficiently well informed prognostically to understand that there was a high possibility of spread to other pelvic structures. However, in traditional medical interviews, she denied this implied fear. It was remarkable that this life threatening traumatic experience was blocked from consciousness. She repeatedly refused the interpretation that her projected anatomical Rorschach response of a "pelvis being eaten by bugs" reflected fear that her cancer had spread. The detailed inkblot inquiry, like traditional psychotherapy, involved verbal communication, a left brain activity.

Over the ensuing years, there have been many such examples observed using the SIS inkblots. For example, one case presented last year in this journal (Cassell and Dubey, 1997)), involved a woman who, in early childhood, witnessed her little brother being killed by sled dogs. She was at a developmental stage when her language and cognitive skills were immature. The viewing of the SIS video at bedtime triggered the emergence of PTSD "nightmares", encapsulating images and emotions of this long forgotten trauma. These memories were apparently indelibly imprinted on her right hippocampus, visual cortex and related areas. It appears that viewing the SIS video, first surfacing through dreams triggered their release.

Such hypotheses need to be investigated by research scientists examining both right-left differences in peripheral feedback of autonomic nervous system arousal as well as concurrent central nervous system activity during experimental inkblot activation of PTSD memories. A multidimensional assessment of body awareness appears to afford the most promise in the envisioned projects. This need is based upon the complexity of the relationships and previous earlier work with a body focus measure of indicating that measures of right versus left body awareness change during pharmacologic (Cassell and

Hemingway, 1970) and physiologic arousal (Fisher and Cleveland,1958; Fisher,1963).

A final consideration needs to be addressed for both investigators and clinicians who plan to employ these inkblot stimulation techniques. Experience indicates the need for words of caution. From the standpoint of the traumatized individual, projectively activating such imagery with inkblots can sometimes evoke strong emotions. Victims of severe stress need to be warned about the risks/ benefits. This approach needs to be restricted in borderline or potentially psychotic individuals. In a related fashion, clinical investigators and therapists need to be advised about the possibility of experiencing potentially toxic empathetic pain with the SIS and Living Images projective procedures. On the positive side, the technology of inkblot video has great pulling power for traumatic imagery, and consequently, enhanced therapeutic potential. On the negative side, it more directly exposes caring professionals to "compassion fatigue" or "burn out". This psychologically hazardous exposure to traumatic images may be historically compared to radiation- induced illnesses, acquired naively by unshielded medical researchers at the turn of this century.

Given these precautions, it appears that Living Images deserves strong consideration for all professionals working with women suffering from the adverse effects of traumatic life events.

Responses of both the cases on Living Image test follows:

Stimulus Plate SIT-5: Butterfly / Contoured Bilateral Symmetry

1. A Chinese guy with a fur ruff...scary...sinister...a wolf.

2. Solar system...outer space...peaceful.

3. It looks like the uterus and fallopian tubes.

4. A pizza being sliced...hot.

5. A bird flying...freedom...light.

6. A fly...creepy...itchy...I am glad that it is going away.

7. A valentine heart beating...its going from good to bad like a telltale heart - like in Poe.

8. A Spanish guy flamenco dancing - chacha...saucy.

9. Two guys about to duel...it makes me feel sad.

10. Siamese twins trying to separate because they are mad at each other...a shame.

11. Blurry twins trying to separate...why?

12. male/female dancing...good times.

13. Pushups...I hated gym.

14. A goofy looking guy with a moustache...silly.

15. A family...mum...dad...& child...security.

16. A scared family trying to hang on to each other ...windy...don't let go.

17. A loving close family...kids look up to parents...it feels good...safe.

18. A doctor examining a patient with head trauma and a really bad headache...alarm!

19. Death...two bodies & undertaker...depressed.

20. An adult kissing a child...a "booboo"..to make it better.

21. Horses...mum and dad...cold.

22. An Easter bunny and a skull...confusion...a weird combination.

23. A lady and kids - teacher in a preschool...finger-painting.

24. A college professor in robes lecturing...boring.

25. Gloom...a mean judge...two scared people...don't like him.

26. A lady winking...flirting...smelling flowers...happy...it looks like me.

27. A doctor symbol...(staff of life?)

28. A flower...pollen in the middle glowing...calm.

29. A creepy face...the bottom teeth showing...trying to scare me.

30. A red haired woman - brain - ideas - puzzled.

31. A snowman juggling scarves - amusing.

32. Ninja turtle ready to fight - it's hostile..I'm not nervous.

33. Hard to make out...a cat face...i hate cats.

34. Gut with a big nose- looking out from behind a curtain - strange.

35. Two skydivers holding hands as they free fall...fun...cool...freedom.

36. St Bernard dog...loveable...hug me...friendly.

37. Dumb dog - hole in head - no face/personality...feel bad.

38. Waitress bringing drink - big drink - glad to see her.

39. A hard-boiled egg between two fat bellies.

40. Baseball hat - really hot day -bald under hat.

Stimulus Plate SIT-1: Core Somatic Grief / Central Structural Focus

1. Musical instrument -haunting.

2. Galaxy...awesome...serene...dynamic

3. Face of insect - curious.

4. Nuclear explosion...radiant... symmetrical.

5. Bird in flight...soaring...powerful.

6. Creatures...inviting...loving.

7. Pulsating heart...warmth.

8. Animated being...caring, joyous, alive.

9. Twins...potbellied - union wholeness.

10. Twins...Siamese - conflict...trapped...angry.

11. Twins...the fuzziness represents effort at relationships.

12. Male/female - marriage...love...union.

13. Vision...iris (i.e. of eye)..- Clarity...searching.

14. Carton cat...fuzzy...funny.

15. Antennas...receptive...informed.

16. Sea Anemones - receptive...informed - lyrical..Light.

17. Parents/children ...family -touching.

18. Solar system.

19. Trees...forest - connected...communication.

20. Drinking from chalice - Holy.

21. Donkeys/lamb - differences...peace versus war.

22. Rabbit/egg.

23. Ocean floor -alien...soothing...eternal.

24. Angel - protecting...nurturing.

25. Confusion - depression...sad...bold.

26. Lady with flower - energetic...thoughtful.

27. Masked vertebrae...uplifting...straight.

28. Clouds with lightning.

29. Butterfly - serene.

30. Angel - reverent.

31. Spider - repulsive.

32. Fish camouflaged - secure and natural.

33. Flowers at sunset - peaceful...vibrant...alive.

34. Cells dividing - busy...important...essential.

35. Egg...fertilized - protected.

36. Symbol/character - continuity...productivity.

37. Female reproductive organs - healthy...glowing.

38. Candle with flower - warm...serene.

39. Eyes - startled...frightened.

40. Egg growing - diversity...cycles...life.

The case study outlines the development and clinical applications of the video, "Living Images". This television technique effectively aides in the psychological evaluation and treatment of a spectrum of feminine health problems. These range in severity from minor stressful situations to severe ones associated with abuse issues and PTSD (Posttraumatic Stress Disorder). Clinical work with the Somatic Inkblot Series (SIS) suggested that this projective technique can be a useful aide in the assessment and treatment of PTSD.

In this case history study, the Somatic Inkblot Series Video, Rorschach Inkblot Test and Figure Drawing tests were administered to a teen age girl who was admitted to a psychiatric Hospital in Boston for treatment of Major Depression and Dissociative Disorder. She had history of suicidal ideation and self-mutilation of her left wrist and forearm. The relaxing instructions in the video and the hypnotically present healing flowers may have facilitated neural extinction of the terrifying hallucinations intruding upon her consciousness. The Figure Drawing and Content Analysis of SIS and Rorschach may provide useful aides to supplement standardized clinical interviewing techniques. The case has been discussed in detail.

The study of hallucinatory phenomenon has long proven of interest. If there is a common clinical bias in evaluating hallucinations, it is the assumption that these perceptual disturbances are evidence of abnormalities in brain chemistry. There is a great deal of supporting evidence for this viewpoint, especially in those with disease of the central nervous system or toxic conditions involving the brain (e.g. chemical induced hallucinatory states). This case history presentation explores the notion, that when there is no clear evidence of neurological dysfunction, the clinician may glean important diagnostic information and novel therapeutic leads by exploring the symbolism in the hallucinations.

This case history presentation involves a teen age girl who was admitted to a psychiatric hospital in Boston for treatment of Major Depression and Dissociative Disorder. Prior to admission, the patient (her fictitious name: S) had experienced severe suicidal ideation with plans involving a variety of suicidal behaviors such as overdosing; slitting her throat, electrocution etc. Her usual behavior involved self-mutilation of her left wrist and forearm. While she had experienced suicidal ideation from the time she was severely abused by a violent biologic father, her pattern of mutilation had only started after she had been removed from high school seven months earlier by her mother and stepfather. Even though she had been made to do home school, she retained communication with a teacher who had been especially supportive of her interests in drama and writing. When she revealed to him her suicidal thoughts, he contacted mental health services who referred her for hospitalization. Her parents initially refused to accept the fact that she had hallucinations and was a danger to herself.

During the initial psychiatric evaluation, she reported that she had previously drawn a colored representation of a reoccurring violent visual hallucination. This was a threatening man with a knife in his hand. Her representation of the figure revealed that he had cut his wrists. Red blood poured from the wounds. When asked to recall who he reminded her of, she said that it brought to mind her abusive biologic father. Upon detailed questioning about her drawing, she told the interviewer that the eyes resemble “mine”.

She was selected for this illustrative case study because she provided a unique opportunity to examine hallucinatory symbolism prior to psychotropic medication. Because she was quite intelligent, she was an excellent candidate for the illustration purposes. She was intelligent with excellent writing skills in poetry and drama. Previously when enrolled in school, she had demonstrated ability in school drama activities to effectively communicate. However, consistent with her longstanding dissociative symptoms, she had extremely limited concern in the expression of personal feelings. Further relevant clinical history will be provided subsequently in connection with her projective test results.

On the second day of hospitalization she was administered the video version of the Somatic Image Series (SIS). The image that she rated as most threatening was B1. A transcript of the detailed enquiry follows:

S: A lot of times. Like when I do theater and someone isn’t so accepting about it. That kind of drags me down (Her parents were adamantly against such activities).

Dr B: Hm hm.

S: It’s just small stuff like that.

S: Yeah.

S: He shows me the way that -- a path that he chose (suicide by cutting his wrists), I suppose, that is also a path that I’ve -- I’ve considered. And the fact that it scares me kind of brings me down.

S: Suicide.

S: Slitting my wrist the same -- same way he did. (it will be shown in her free associations to subsequent sis images). S had been severely traumatized by her biologic father, and had partially identified with “his violent personality. This identification was reflected in her comments about the eyes in the figure resembling her own.

Next her associations to SIS B21 will be explored for symbolic content. She had rated this image as third most threatening.

Dr B: Okay. For B21 you said: “Anything that hurts nature angers me”. Okay. It angers me too. And you see.....

Dr B: And what does that bring to mind.

S: I don’t know. It just -- it brings to mind a disruption in -- in the beauty. I mean.....

Dr B: Right.

S: Nature and earth is so amazing, and it’s so) inspirational and the fact that some.....

The next response that warrants projective analysis was produced in regard to her viewing B22. Here she envisioned a “person sleeping with dreams so disturbing it causes them illness” Consistent with this, in association with the visual hallucinations of a figure with a threatening knife; she had recurrent posttraumatic dreams in which a similar figure slashed his own wrists and then chased her.

In this regard, the violent hallucinations simply reflected a spillover into conscious awareness of the violent night time imagery and emotions. Sometimes, the violence in dreams was directed at her friends as illustrated in her response to SIS B22.

Dr B: Then twenty two B. “A person sleeping with dreams so disturbing it caused an illness”. And what does that bring to mind?

S: Myself.

S: They’re horribly violent.

S: One I ha -- I recall a lot is a friend of mine getting killed because a bowling ball fell on his head.

S: They were real looking. What do you mean? I’m sorry.

S: Yes, there was bones and blood and.....

S: It hurt. I mean I cried and I was.....

S: Yeah.

S: It lasts throughout the day.

S: Yeah.

(Even though this was a horribly disturbing dream, she still was able to recall it, since it was much less anxiety provoking than her terrifying dreams of the knife threatening hallucinatory figure).

Next attention will be given to her reaction to B15 the only SIS image that had embedded structure of knife like sharp objects.

Dr B: Okay. B15 “Knives being thrown at someone to cause them more pain”. What does that bring to mind?

S: Me.

S: Because sometimes the pain that I feel it -- it feels like somebody’s taking a knife and stabbing me (Here, she compares her somatic pain in terms of a knife stabbing her).

S: In my stomach and in my ribs and my heart (Diagnostic medical studies had not revealed any physical problems to account for her discomfort. Consequently it was assumed that they represented Conversion Reaction symptoms related to her Dissociative Disorder).

S: Oh, it feels horrible. It’s -- it’s just -- it’s burning and it’s -- I don’t know. It’s just sharp pain.

S: Same thing.

Next the detailed inquiry in regard to SIS Images A10 and A12 will be explored in terms of their related body symbolism.

S: I don’t know. It just looked like somebody who is sad and in pain.

S: Yeah.

S: It’s hurtful.

S: Everywhere.

S: Sometimes.

S: It feels like sharp shooting -- well, it feels like somebody’s stabbing me.

S: An ear with blood in it. (The blood response projected here is quite consistent with knife bleeding).

As will be shown subsequently, Stephanie was a victim of severe childhood psychological, physical and sexual abuse. Associated with the resultant traumatic events she had blocked from conscious awareness many of the events along with their related painful affects. Consciously, when triggered by current stressful life events, these were experienced as somatic pain.

Next, her response to B27 will be outlined.

S: It brings to mi -- to mind myself and -- and like the darker half winning over the better half.

Dr B: The good part.

Dr B: Yeah.

S: Happy.

S: Controlling, dominating, hurtful.

In interpreting the symbolic significance of human content in visual hallucinations, it may be inferred that the figure symbolically represents an aspect of the person’s own self. For Stephanie, the male figure of the hallucination symbolized both her father and her violent tendencies. The latter resulted from her learning aggressive behavior from her abusive father (i.e. mutilating her wrists). Of course, genetic factors may also be determinants.

Next, historical information of childhood trauma follows in regard to her associations to A22.

S: The way people are affected by certain things.

S: Yeah.

S: Hard. It was painful.

S: My dad for the most part.

S: He would hit us and throw us against the wall. And stuff,(Her mother reported sexual abuse, although at this stage in her psychotherapy with her female therapist she was amnesic to this early trauma).

Next, her comments about A18 are relevant to understanding how the dissociation process fragmented her personality.

S: Me.

S: Because I have problems with communication. And it seems that I just have barriers that I put up.

Next her discussion in relation to B4 throws light on her distorted cognition presented in her mutilation poem presented at the beginning of this article.

S: Because one of the images is a lot uglier than the other one.

S: That would be the image that I don’t present. It’s distorted over things that have happened.

S: Such as my dad being mean, or something as little as Jessica leaving (One of the losses that precipitated her current depression was Jessica’s moving away. They then communicated frequently by e-mail. Eventually S shared herself mutilation secret with Jessica. Jessica, in turn then sent her the drawing presented in figure, indicating that she too found “Peace through cutting” poem with Jessica about herself mutilation, that she also did the same).

S: Pain.

S: Yeah.

S: The anger at themselves.

S: Part of the reason I cut myself is because of the anger I feel towards myself.

S: It sees something being released.

Dr B: Hm hm.

S: Something being set free.

Next, her response to B20 depicting a human brain portrays her distorted cognitions and auditory hallucinations.

S: Me.

S: My lack of concentration now. And my inability to recall things that happened to me three days ago In Dissociative Disorder, amnesia is a common symptoms relating to overriding attempts of her mental defense system to obliterate emotional suffering.

S: It feels damaged.

S: Yeah.

S: Jumbled noises.

S: They kind of throw me off and upset me for a bit, until I can like try and regain myself.

S: It just sounds like everybody is jumbled.(These auditory hallucinations are of concern. They could indicate that she was suffering from the early stages of one of the Schizophrenic Disorders).

Next, her responses to B29 and B30 are of interest because they provide an opportunity to assess, through the mechanism of projection, how her hallucinations affect her. This additional aide in assessment was clinically important. Initially, neither her mother nor stepfather would believe her or the hospital staff that she was truly hallucinating.).

S: Me. I run from everything.

S: A lot of times. Just out of the blue, sometimes, I’ll be really scared and -- and when I hallucinate I feel scared and just -- yeah.

Dr B: B30. “Two ears each hearing something differently”. And what does that bring to mind? (This depiction of human ears is particularly useful. It enables those suffering from auditory hallucinations the opportunity to communicate about their suffering. The material which follows more sharply brings into clinical focus her dissociated mental processes).

S: Everybody. Everybody seems to hear something different then everybody else. And sometimes they hear two different things that weren’t even intended and.....

S: Yeah.

Dr B: Tell us about it.

S: Sometimes I -- I -- I hear things telling me what a bad job I’m doing, and everything.

S: Yeah.

S: Really bad. It makes me feel weak.

S: No (here she reveals (by elimination of suicidal voices) that it is primarily the visual hallucinations which contribute to her mutilating behavior).

S was tested with Rorschach one week after admission when she was still having hallucinations. The report read as follows: “Her responses to the Rorschach cards were first scored with the Exner scoring technique. Mostly her responses were scored within normal parameters. At the time of this assessment, she appeared somewhat depressed, but not necessarily suicidal. She did, however, appear susceptible to episodes of affective disturbance that may involve features of worthlessness and confusion. She tends to make decisions based on how she feels rather than on what she thinks, although she tends to be confused and uncertain about how she feels much of the time. She appeared to be experiencing considerable emotional stress that was interfering with pleasure in life and making her susceptible to becoming even more depressed and anxious”.

“The contents of her responses were interesting and seemed related to the contents of her hallucinations and dreams. One perception was of a “horrible, ugly giant with big, mean hands and huge feet”. She described another as something “rough on the edges like something that’s been cut up”. Another was a “scary face with an evil horrible grin with awful sharp teeth”. These references were consistent with hallucinations featuring a man with a knife, cutting himself and threatening to cut her”. She was subsequently interviewed by Dr B 30 days after her admission. She was asked the question: “Did you see anything in any of the Cards which reminded you of the figure in your visual hallucinations?”

S: Yes (selecting Card II), I see his face. There are his eyes (pointing to the blank space under the upper red colors).

S: Yes, he is frowning.

S: Lonely

S: It looks like he is crying. His eyes are red.

Assessing the symbolic significance of hallucinations poses serious methodological challenges. Ideally, the clinical investigator should attempt to obtain valid and reliable data at the time the subject was experiencing a particular hallucination. These data could be compared with projective responses in the non hallucinatory state. While this may have appeal to those who champion scientific rigor, like dreams hallucinatory episodes are constantly in flux. Moreover, because of a variety of complicating factors - not the least of which is the individuals confused cognitive state and inability to clearly demarcate boundaries between actively psychotic and dormant psychotic conditions, such rigorous comparison are not always practical. In addition, the prime emphasis must always be on therapeutic issues. This case study has many limitations, active psychotherapy was going on over the course of treatment and psychotropic medication levels were being brought up to therapeutic levels.

In spite of such limitations, perhaps a general observation can be made which could provide guidelines for future clinical investigators. In the absence of clear-cut neurological illness, it may be hypothesized that direct and/or symbolic information that can be gleaned by the assessing hallucinations. In assessment, projective techniques such as figure drawing, and content analysis of the SIS and Rorschach stimuli may provide useful aides to supplement standardized clinical interviewing techniques.

In this case history study, the SIS-II Video was used on the second day of hospitalization when the hallucinations were frequent and intensely threatening. When Stephanie viewed the SIS evidence of their presence was only symbolically inferred from two of the three images that she rated as most threatening: Images B1 (“A claw reaching from the depths to drag you down” and B21 “An oil rig reaching into the beautiful earth to suck her dry”). While at the time, these were rated as quite disturbing, it could have been potentially much more disruptive to her fragile cognitive state if her mental processes had not employed symbolic defensive overlays blocking the intruding hallucinatory imagery of “The man with a knife”. Moreover, the relaxing instructions in the video and the hypnotically present healing flowers may have facilitated neural extinction of the terrifying hallucinations intruding upon her consciousness.

One week later she was responding well to treatment. Self mutilation impulses and visual hallucinations were infrequent, yet her Rorschach responses showed content consistent with the face of a threatening man. However, no specific inquiry was done concerning what her facial responses brought to mind. A month later in treatment, when she was given an opportunity to view all Rorschach plates laid out on a table in response to a specific inquiry she spontaneously indicated that the imagery evoked by Card II resembled the hallucinatory man’s sad face with reddened eyes. Consistent with her clinical improvement, there was no reference to his cutting behavior; blood etc. and he seemed much less threatening.

In psychotherapy the following day, she was asked why she thought that he was sad. She said that she didn’t know why. When asked if she felt sad, she immediately answered in the affirmative. Two days before, she had been crying profusely and was “red eyed” herself. As indicated earlier, hallucination represented a composite image of her abusive biologic father and her own dark side.

As she got in better touch with her sadness and emoted during therapy sessions, the visual hallucinations stopped. The imagery was replaced by her sensing the psyche presence of the man standing behind her. In a paranoid way, she imagined him to be contemplating touching her shoulder in what she feared would be in a menacing fashion. However, she envisioned that he no longer had a knife in his hand. At this time there was a reduction in her suicidal ideation and impulses to mutilate her wrists.

Her improvement was reflected in her writing the poem which shortly follows.

Finally in considering the significance of hallucinations whose etiology is primarily not neurological, it might be useful to consider certain of the psychological origins of their symbolism. Like many adolescents who have experienced severe childhood trauma and develop Dissociative Disorder, Stephanie’s mental defense system became disrupted. Thus she suffered from a breakdown of the usually integrated functions of consciousness, memory, identity and perception.

The latter disturbances involved both the outer world and of her body image. She had been depressed for years and long had experienced suicidal ideation. Death in her fantasies provided her a way out of her painful existence. Her self-mutilation impulses were first acted upon when she was taken out of school. For her, this was a devastating attack on her fragile sense of identity. It shut off her outlet in regard to drama and writing - all things that her parents despised. Not being able to express her rage directly to them, she acted out her anger on her body. When she found the act of bloodletting giving her an emotional release, she developed an almost addictive behavior to this.

Her Internet friends reinforced this maladaptive self-abusive behavior - as illustrated by the friend who sent her the “Peace through cutting” drawing the Figure. She also had so-called friends in cyberspace with suicidal behaviors that also had eating disorders. Consistent with familiarity to the latter, she responded to A7 as follows: someone trying to deal with an eating problem, trying to make healthier choices”. In the initial inquiry, she denied having this problem herself. However, in the second month of therapy, she finally revealed that after listening so much to their fears, she too had become concerned about her body image. Since self-destructive behaviors can sometimes be readily transmitted from one person to the next, her Internet “Chat room” was a highly dangerous place for this suggestible adolescent girl. This case illustrates why twenty first century clinicians need to inquire into Internet activities in exploring determinants of violence.

The relaxing instructions in the video and the hypnotically present healing flowers may have facilitated neural extinction of the terrifying hallucinations intruding upon her consciousness. The projective instruments may provide useful aides to supplement standardized clinical interviewing techniques.

Mental disorders are less tangible than medical conditions that ordinarily have more objective diagnostic determinants. For the former, objectivity in interviewing may be enhanced by the clinical application of the SIS projective technique. This semi structured series of semi structured “inkblots” provide a symbolic source of data which can enrich traditional diagnostic/treatment processes. The projected symbolism can tap into rich healing streams of natural spirituality not reachable by non-projective techniques. This approach’s clinical application will be illustrated in a twenty one year old female medical student suffering from Bipolar Depression (BD).In the past century this potentially serious condition, like Schizophrenic Disorder, captured more attention of psychometricians. While modern clinicians generally recognize the critical importance of pharmaceutical treatment modalities, medications still have limitations in efficacy. Clinical investigation is needed to determine innovative ways to supplement these with adjunctive psychological therapies. The present case history illustrates how the SIS can detect symbolic imagery invisible to the viewer, yet symbolically visible to the psychotherapist.

Because of their intangible nature and fluctuating course over time affective disorders pose challenges in evaluation and management. This occurs in Bipolar Disorder (BD). In this cyclic disturbance, an individual’s mood state at one stage may be euphoric and then, shortly afterwards the opposite. Objectivity in assessment is enhanced by the Somatic Inkblot Series (SIS).

This projective technique can provide a symbolic source of clinical data enriching traditional diagnostic/treatment processes. The symbolism can tap into rich healing streams of natural healing imagery not discernable with other assessment techniques. Projective information can be released either directly or in symbolic form whose historical significance may be invisible to the responder. This will be illustrated by means of a case history presentation involving a twenty one year old female medical student in a depressed phase of BD.

There are many puzzles in attempting to put together a scientifically sustainable hypothetical model for BD. An interesting one involves the observation that intellectually endowed creative individuals are more prone to develop this condition (Santosa et al, 2007).

Biological Dimensions of BD:

While this affective cyclic syndrome is categorized as a “mental disorder”, like many, BD appears to have an underlying genetically determined neurobiological component. Those suffering from this manic or hypo-manic phases of disorder frequently have a positive family history (Kelsoe, 2000, McGuffin et al, 2003). Moreover they tend to have a characteristic response to specific types of medication. Mood stabilizing drugs directed at altering neurotransmitters (e.g. Lithium, Valproate, Lamotrigine etc) are indicated as the primary treatment agents. In sharp contrast, antidepressants are contraindicated, if contemplated as the sole pharmacotherapy approach. If mistakenly administered in the absence of a mood stabilizer, they may aggravate the condition.

BD can be life threatening (Osby, et al 2001). It has been estimated that approximately five percent of sufferers commit suicide. Over the longitudinal course of the illness noncompliance with medication is a common problem. Fortunately with accurate diagnosis and appropriate therapy necessarily involving medication supplemented by appropriate psychological intervention, the prognosis may be positive.

Modern studies focusing on the neurobiology have reported a reduction in the density of regional brain neurons. In comparison with matched controls, a magnetic resonance imaging one study reported that BD patients show a 39% reduction in left subguenal prefrontal cortex gray matter volume (Drevets et al, 1997). Remarkably enough, there is evidence suggesting that medication may have both neurotrophic and neuroprotective effects (Gray et al, 2003).

Diagnostic Dilemmas:

BD is a recurrent affective condition having mania or hypomania at least once. Over the individual’s lifetime, the affective highs are usually intermixed with episodes of debilitating depression. Diagnostic guidelines have been set out in DSM-IV and the International Classification of Diseases -10 (Ghaemi et al, 2008). Recently members of The International Society for Bipolar Disorders (ISBD) have proposed revisions because of ongoing problems in diagnostic categorization (Mitchell, et al, 2006).

One concerns the fact that Unipolar Major Depression is sometimes erroneously diagnosed, instead of BD (Stensland et al, 2008). Since there is a high degree of symptom overlap between the two, clinicians sometimes fails to consider the longitudinal history involving undetected mood elevation episodes (Kerr et al, 2005). Ideally, in view of the protracted time dimensions, projective assessment should be repeated periodically to documentation of the cyclic mood swings. SIS based electronic records documenting such fluctuations represent the wave of the future.

A longitudinal approach is essential. Individuals with elevated mood may experience cognitively impairing euphoria causing them to lack insight into their abnormal mental state. Moreover, once they subsequently slip into depression, usually for periods that are much longer than the highs, their memory for their previous affective elevation may become blurred. To complicate the dynamic clinical picture in the euthymic state persistent low level neurocognitive defects can further blur insight (Zubieta, 2001, Nowatowska, 2005).

In severe cases, the contaminating presence of features such as delusions and hallucinations may mimic a variety of psychotic conditions. At the lower end of the severity scale, the clinical presentation can mimic fluctuating mood states in psychologically stressed individuals, such as those suffering from Post-traumatic Stress Disorder (PTSD).

International studies are in progress designed to throw light on BD’s cyclic nature, as well as to identify optimal treatment strategies. For example, in the United States there is a national longitudinal study called the Systematic Treatment program for Bipolar Disorder (STEP-BD, Sachs et al (2003). Examples of the information that have been derived from are the following. Of those with BD who met the criteria for recovery, approximately 5% relapsed each month, and about 80% manifested depression. In regard to rapid cycling, 32% met the criteria. There was also a high co-morbidity rate with substance and alcohol abuse.

In recent years, BD has been diagnosed much more frequently, especially in children and adolescents Moreno et al, 2007). In this age group, the disorder may be expressed as affect storms presenting a clinical picture resembling Attention Deficit Hyperactivity Disorder and various adjustment disorders. In America the trend to diagnosis BD more frequently is not without controversy (Zimmerman et al,2008) Geller, 2008 found that grown up subjects with a history of Bipolar-I Disorder are much more prone to develop manic episodes than population prevalence. It was also found that low maternal warmth predicted relapse to mania.

BD Depression:

At present clinical investigators have no clear cut reliable diagnostic criteria for categorizing BD depression Mitchell et al, 2008). Consequently there is a pressing need for psychobiological research. Moreover there is ongoing controversy about management since treatment strategies may be quite different throughout the mood cycle. The depressed phases occur three times more often than the affect highs (Judd et al, 2002) and last for longer periods (Miklowitz et al, 2007). Formulating an optimal case specific pharmacological/ psychological treatment plan during the depressive phase can be challenging.

In our present state of knowledge, there may be potential pitfalls in the use of antidepressant medication, even when used in conjunction with a mood stabilizer. Although many experienced clinicians believe that mood elevating drugs may be temporarily indicated, there is criticisms regarding this treatment strategy. Critics contend that antidepressant likely has a lower efficacy in BD depression based upon controlled studies in which the data do not support any real mood elevating benefits. Moreover, there are potential risks since in the STEP-BD study those who received antidepressants were 3.8 times more likely to experience rapid cycling during the follow-up year. At present this still is an unresolved treatment issue.

Adjunctive Psychosocial Treatments:

In view of the above, recently psychosocial treatments have been more widely studied. For example, in the STEP-BD longitudinal study, 293 outpatients treated with protocol medication management were randomly assigned to intensive psychotherapy (30 sessions in 9 months) or collaborative care (3 sessions in 6 weeks).Those participating in intensive psychotherapy had statistically significantly better recovery rates.

Consistent with research focusing on psychological adjunctive therapy, the following case history explores the use of SIS in BP Depression.

Clinical History:

The 21 year old female was first diagnosed with BD in her early teenage. At that time she was initiated on mood stabilizing medication which enabled her to continue her medical studies. During later adolescence there was one stressful episode worth of comment. During a depressive phase because of poor motivation, she received an unusually low grade in class 5 on a term examination. With the prompting of a boy in her class and to avoid her family discovering it, she tore up the report. After learning about this incident, her teacher ordered her to inform her parents. Fearing their angry response, she stayed away from classes for a month in a stressful state of “terror“.

When her parents discovered this, their concern for their talented daughter motivated them to seek a tutor. After enquiring they found an educated compassionate man to tutor their daughter. At the time his health was somewhat marginal due to a congenital heart problem. The reason that he was available as a tutor was his poor health which had previously prevented his achieving a higher level of employment in the Indian railroad.

As part of the tutor employment contract, he moved in with the family. Gradually over a four to five year period her respect and affection for him grew. Eventually he became a positive mentor for her so that she began affectionately calling him “Uncle”. With his effective tutoring and psychological support, she then became a successful student.

Eventually she moved away from her village to Delhi for higher level education. After two years her “Uncle” partially faded from her mind. As was medically expected, during this period his cardiac function drastically deteriorated .When it became life threatening, he contacted the girl’s biological uncle for assistance. This man facilitated his emergency hospitalization in Delhi. Little could be done medically and as a result he died shortly after being admitted. Unfortunately her family had not realized the psychological importance of her “uncle” to their daughter and failed to notify her in a timely manner.

Initial Interview:

In the initial interview prior to SIS assessment, the interviewer when enquiring into her past history learned that her later life BD symptoms had intensified after a moving to attend schooling in Delhi. Away from her family, she felt homesick and lonely. Previously she was an outstanding student planning to prepare for medical school entrance examinations. Initially she achieved sufficient grades to enable her to register for dental education. However, since she was motivated to become a physician, she had to repeat the year in order to obtain higher marks. Then she was successful in getting accepted for medical school.

Next relevant information was obtained regarding the more recent stress related to the death of her “Uncle”. In speaking about this she emphatically complained that her family’s oversight had “hurt” her deeply. She seemed bitter and angry. She complained that her parents were “without feelings”, “thankless” and “selfish”.

From her overall clinical presentation it was readily apparent to the interviewer that she had not processed her grief. She was preoccupied with affect charged death images of her “Uncle”. A vivid example of this preoccupation was reported. She recalled projecting an image of him onto a person in a TV serial. This individual was apparently suffering from a similar congenital cardiac condition. She pessimistically imagined that he would also die and found the television program quite upsetting. During this period she became more noncompliant with the prescribed medication and her BD depression worsened. Recognizing this, her psychiatrist referred for SIS assessment.

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Relevant Answers to the SIS “Brief Health History”:

Her current medication involved a mood stabilizer (Lithium Carbonate 800 mg daily) and an antidepressant drug (Stablon 12.5 mg TDS). (During the early years of pharmacotherapy she had been relatively compliant. However, especially since learning of her tutor’s death, she claimed that medication was not helping her. This was her rationalization for not following her psychiatrist’s medication plan).

In answering the pain related SIS questions, she complained of “generalized body aches” and “painful knees”. Somehow in her depressed state, she pessimistically perceived her somatic discomfort as aggravated by the medication. In regard to the question about “somatic focused anxiety”, she reported concern about “breast and tummy” - “breasts too oversized and tummy too large with fatty sides“.

Lastly under the heading of mental problems she listed the following: “ Insomnia…overeating…inferiority complex…make a plan daily but rarely implement them…hope that the next day will be better…feeling detached to everything… including family members”.

Responses to the Booklet Version of SIS-II:

In preparation for viewing the projected SIS responses the interviewer is well advised to adopt an empathetic posture. Unlike non projective tests that foster cognitive detachment, the SIS requires emotional involvement and intimate identification with the responder. Part of the reason for this may relate to the conceptual model of infective empathetic communication. If someone observes another yawning, this involuntarily activates a reflex neural stimulus engendered in the observer’s brain to yawn. Basic science studies indicate that this reflex is experienced in a variety of animals.

Apart from yawning, various emotions are similarly reflex transmitted between humans. With regard to BD, an ideal solution for a professional who feels down after empathizing with an individual in the severely depressed phases, is to next see one with a hypo manic infectious euphoria. Of course this is not realistic, but it does illustrate the point of discussion. Regarding empathetic transmission of feelings in clinical interviews, these are analogous to using a low power microscope in inspecting pathological slide. In contrast, when the SIS clinician inspects graphic affect charged symbolic SIS responses, the affect transmission is much more vivid. It is comparable to a high power microscope enabling the viewer to more actively empathize with the depths of psyche suffering.

Yet this can expose the interviewer to secondary empathetic trauma. For example, if a psychotherapist is treating military victims of PTSD tormented by “mutilated” body imagery in their recurrent nightmares, this clinician’s brain will be flooded each day with similarly stressful symbolic SIS responses. Fortunately, this degree of stress will not be reached in the case under present review.

To maximize the empathetic connection with this suffering medical student, consider first entering a yogic state of meditation. Then independently view the SIS-II Booklet series of images compare and contrast your subjective feelings and perceptions of the SIS stimuli with those reported by her. This proposed exercise might be best done at your bedtime. In this way, you may program a blending of your own inner world visions, with those projected by this suffering young woman. Perhaps what you subsequently dream may mysteriously merge her unique images reflecting positive, neutral or negative spirituality with your own.

Assessing SIS Responses:

Initial attention will be her response to the three “Most liked” SIS stimuli:

A13: Was the third image which she liked the most “Someone being trapped there and asking for help…this card conveys great meaning…and I praise the art.” She also liked that it had “great meaning” since it further allowed her to express her “trapped” feelings. She appreciated having established positive rapport with the interviewer. In spite of her depressed mood, she still had persistent hope that treatment would help her. Overall, the above projective material evoked by A13 suggested that there might be a better outcome hope if her family were involved in counseling to improve communication and restore childhood based affectionate bonds.

The three “Least liked” SIS stimuli were as follows:

B29: “A child is running inside home…very scared” This symbolically portrayed her regressive wishes to magically travel back in time to the happy bliss of childhood. The symbolism also reflects her high anxiety. In her inner world she yearns to be safe again “as a child”. Clearly this fantasy could not be fulfilled in the real world, so she felt “very scared”. Apart from having BD, the life of a medical student is highly stressful (Streeramareddy, et al 2007). She had the additional stress of feeling isolated from her family.

B12: “A person trapped in the desert dying of hunger and thirst” This symbolically again depicted her sense of isolation and imprisonment.” She was “hungry” for emotional support and sustenance. The severe death symbolism signaled the need for follow-up enquiry into possible unreported suicidal ideation. It will be elaborated upon further in considering B13. The fact that she originally wrote “Devil” instead of “person” will also be discussed subsequently.

A27: Here the “vulgar breast” reference is consistent with her body image disturbances reported in the Brief Health History, and dissatisfaction with her feminine body image. Given her sense of social isolation, it is understandable that she has turned to food for emotional nurturance -ultimately causing weight gain (“fatty sides”). This information needed to be appraised clinically since her weight gain could result from an unwanted side effect of her medication. This may have played a key role in her reluctance to continue the medication. (In the longitudinal treatment plan, the risks/benefits of psychotropic medication are always an issue. Unfortunately with long term Lithium therapy, sometimes thyroid function may be depressed. This endocrine deficiency if untreated can lead to new mental problems, low energy, depressed mood etc).

Next attention will be given to other clinically relevant SIS responses as follows:

A2: “A Devil.” This SIS stimulus was highly threatening to her. It took 85 seconds to emerge in projective consciousness before being reported. The content denotes an evil representation, which culturally may depict her previously noted negative impression of her parents. In her inner world is might also symbolize how she thinks about this aspect of herself for her satanic like rage towards them.

Her psyche is being torn apart by the internal battle between good and evil. Her positive impulses and wish for spiritual peace surfaced protectively in visualizing B13 as Mahatma Buddha’s face. In terms of depicting her inner struggle, the timing is noteworthy. This beautiful symbol was brought to the surface in spiritual consciousness, immediately after the demonic one, evoked by B12: “A Devil dying of dehydration in some desert area”. The outcome here with the “Devil dying” points to her residual hope that the positive forces within her will overcome the satanic ones. It is noteworthy that at the end when rating the responses for threat, she wrote “person”. Here the substitution signified a repression of the evil - a mental victory for the forces within her for good.

Some of those devoted to SIS intervention may choose to address this struggle or refer her to spiritual advisors. It is a universal battle that humans philosophically face.

A3: “A scarecrow with hands widened.” This symbol continues at a lower level of intensity her anxiety charged projection onto A2.

A5: “Some transverse section.” People in the medical field frequently project anatomy responses. Consistent with this familiarity, she gave a total of twenty one anatomical responses. This pointed to her hypochondria and somatic anxiety, apart from “familiarity”.

Her second vision is also clinically relevant. “A person standing with a halo…may be an angel and pigeon flying over him.” This “person” denotes her deceased tutor, who was such a good surrogate “uncle”. This symbolism will be elaborated upon further in reviewing A6 “Some kind of ghost.” Commonly the culture based irrational notion of “ghosts” symbolize souls of deceased people. It might be inferred that this response again reflected preoccupation with her “uncle”. Recall that she reported having emphatically projected a death image of him, while viewing television.

Follow-up questions need to be raised regarding the possibility that she may be dreaming of him. Perhaps she might also similarly sense his supportive spiritual presence while awake, or with Yoga meditation. In a future psychotherapeutic interview, it might be helpful to correct any fears that she might have from this “irrational” experience. The interviewer might reassure her that many grieving humans have similar spiritual loving visitations from a deceased one. This reassurance could augment hope thereby facilitating future positive spiritual growth and healing.

Finally attention might be given to the third mental picture projected “A ball…as making a furious gesture.” This again reflected her fury at the family’s neglecting to immediately inform her of his emergency hospitalization. She felt “deeply “hurt” and cheated.

A14: “A pretty girl standing on a lonely beach with a rock behind her.” This represented a direct projection of her desired body image and loneliness.

A24: “It is a blind well and two people are thrown. At a personal level this again symbolically depicted her sense of being “trapped”. At an interpersonal level, it may have denoted her initial rage towards her parents for their delay in informing her of her tutor’s hospitalization.

A30: “A ghost or someone wearing a mask.” The “ghost” symbol has been previously reviewed. The “mask” symbolizes her external persona.

B2: “Some kind of fat Devil.” The “Devil” symbol again emerged only this time as “Fat”. As noted, on the inside her rage may make her perceive this aspect of herself as a “Devil”. The “fatness” referred to her own negative feelings about her obesity.

B4: “A young and old ghost discussing in darkness.” The “ghost” theme continues. Perhaps her response could depict her memories or dream imagery of conversations between herself and her deceased tutor.

B17: “A face in darkness..may be a ghost.” Here, in spite of her heightened projective awareness of anatomical SIS structure, her visual apparatus inhibited the cardiac structure embedded in the external stimulus. What was substituted was her tutor’s “ghost” imagery. An additional determinant of the somatic repression may have been that her “uncle” died as a result of heart pathology.

B18: “Two thieves standing in darkness planning something”. Here she failed to detect the phallic symbolism substituting symbolism related to the battling satanic forces of evil raging inside. Some of the conflict might relate to her cultural and educational need to postpone sexual gratification.

While other responses are of interest, only two others will be analyzed, both “invisible “to her:

B22: It involved her failure to recognize the SIS structure as “A person dying whose soul is leaving the body”. Of course not all responder see this, but it view of her “uncle’s” recent death, this avoidance was psychologically significant. Notice that when mentally processing this figure, her mental mechanisms transformed it into a vertical position to avoid the dying posture. Then her mind projected onto the figure regressive characteristics of “A small boy standing alone thinking about something”.

B28: “Somebody posing for a health magazine”. This in itself is not unusual, since it long has been known that students entering the health sciences have higher health concerns than other groups. However, her failure to detect a loving image of a mother holding a child also has significance. It reflected her emotional isolation from her mother.

Let us have reverence for the healing spirituality surfacing in this young woman suffering from BD depression. Several of the noteworthy symbols projected reflected her ongoing struggle between life and death forces within her. This symbolism would indicate the importance of immediately checking again fo unreported suicidal ideation.

After such precautionary questioning, interview attention might be given to the highly stressful loss of her tutor, which resulted in unresolved inhibited grief . Her need for follow-up therapy to assist in grieving was dramatically illustrated blindness to the invisible dying figure in B22. Because of the intensity of her repression, hypnotherapy exploring this response could facilitate releasing her grief imagery. A case that was presented years ago in this journal described how hypnotically viewing the embedded structure in B22 therapeutically released frozen grief (Savage, 2001, 2004).

Her detachment from the emotional support of her mother was reflected in her response to B28. Like her response to A13, this brought out the need for family psychosocial intervention. Given these events, it is understandable how BD depression deepened producing new symptoms. One involved her noncompliance with medication, which further added to the downward mood spiral.

Perhaps the SIS facilitated trip into this young woman’s invisible inner world may have induced some degree of secondary empathetic dysphoria in the reader. Exit this self induced state knowing that what you have learned, may helpful in administering the SIS.

The analysis of her overall responses illustrated how in such a case, the interviewer need not just focus on differential diagnosis considerations. The projective data may be examined to throw light on a variety of other clinical issues, such as what accounts for medication noncompliance. Are there unreported safety issues such as suicidal or homicidal ideation? Are there unreported distortions in the individual’s transference of distorted perceptions onto the image of the therapist, based upon current stressors (e.g. death of a supportive figure). What is the psychological coloring of somatic symptoms ranging from anxiety/stress arousal related psychophysiologic discomforts at one extreme of a spectrum to psychotic somatic delusions at the other? Are their concealed paranoid fears of taking medication etc. etc.?

All who devote themselves to becoming masters of this projective technique are again encouraged to empathetically move away from the emotional distancing associated with non-projective testing. This invitation involves establishing a personal tutorship type of psychotherapeutic relationship to release nature’s inherent life healing forces. Be guided in using our SIS structured interviewing by the rich Indian history linking a Yoga master’s devotion to a novice trainee.

The interpretations were presented modestly and we realize that each reader may have different innovative insights. After all, interpretations of projective responses have to be filtered through a lens comparing normative response data, with the interviewer’s own subjective colored SIS stimulated imagery. In viewing B22, most interpreters would likely have potentially distorting emotionally charged memories involving death of a loved one. If verbal associations to a projected grief response to B22 were being explored concurrent with a clinician’s anniversary reaction, this likely would strongly influence the interpretation/therapeutic recommendations.

This projective technique-SIS has been found to provide a powerful symbolic source of clinical data enriching traditional diagnostic processes. The symbolism can tap into rich healing streams of natural healing imagery.

Stimulus Plate SIT-2: Trauma Processing / Motor Dynamic Plate

Many perceive image A2 as reflecting people in ordinary activities. In sharp contrast, imagine that a few days earlier you had assisted at an automobile accident. The victims were family members who had been seriously injured. You heard their screams and gasps for breath. You witnessed their bleeding broken bodies and smelled body odors. You didn’t know who you should first help but you rendered first aide.

This included saving a child’s life by giving mouth to mouth resuscitation. After you left the accident scene, you were still confused and so emotionally upset that you vomited. You were embarrassed by your reaction and felt irrational guilt for not having saved everyone. You decided never to share your traumatic experience with anyone – not only your partner you loved!

If this had been reality, in all likelihood for several days, traumatic memories and scene specific upsetting images would have intruded on your daytime consciousness. At night, emotionally charged accident scenes would likely have appeared in your dreams. Eventually most of the posttraumatic symptoms probably would be forgotten, unless triggered by the sounds of emergency vehicle sirens.

A few years later, imagine that you became clinically depressed after your love relationship failed. The person complained that you never communicated what was in your mind, or expressed your feelings. She had noticed these communication blocks about the time that you had started walking with “Nightmares”. Since you had never told her, your lover had no idea that your communication inhibitions had been aggravated by an accident in which you saved a child.

Due to the severity of depressive symptoms at work, imagine that you were advised to seek professional mental health services. Your psychotherapist correctly noted that your depression had followed the loss. In addition, your family history suggested that a genetic based pattern of emotional repression. However, it was not until A2 was shown that a comprehensive posttraumatic treatment plan could be established. Imagine that you responded as follows: I see a family. There is a father and mother with children. There has been a terrible accident. A drunk driver has smashed into their car head on There is blood all over. I still can hear their screams.

Comparable stress specific scenes haunt the dreams of emergency workers, traffic police and in combat veterans. The same applies to the “Nightmares” of children in war torn countries. Most cultures choose to look the other way or actively deny the existence such material by claiming: “That is normal for children to have nightmares. They mean nothing!” Many cultures advocate the myth that masculinity and certain professional roles require denying painful emotions.

Consistent with this, traumatic events in children are ordinarily neglected, especially in inner city dysfunctional schools. Yet a suffering child may, in disguised form project his inner turmoil by creating art forms, or in symbolic sand tray play with dolls or toy human/animal figurines. A SIS psychotherapy approach supplemented by Sand tray educational video is available illustrating the diagnostic/treatment value of combining these approaches in traumatized children. The above case is based on a real clinical case as follows:

In 1989 when an Alabama policeman viewed the “SIS inkblot” A2, PTSD imagery surfaced. The color-form structure in the SIS presentation reminded him of an accident scene that he had attended 15 years earlier. He visualized critically injured people with blood pouring out of their multiple wounds and remembered how emotionally upsetting this had been. The next morning when interviewed, it was learned for a considerable period of time he had suffered from PTSD symptoms which had been previously untreated.

With the SIS he vividly recalled an incredibly stressful automobile accident that he had attended years previously. A transcript of the interview follows:

J.: It’s been about two weeks.

J: Sure.

J: It looks like an image of two sea horses. Those little tiny sea animals facing each other with a glass up the middle.

J: I really don’t have much feeling about that one.

J: That one. I see a man on the left side here. He’s holding on. He’s got his arms out. I see a child here on the right side and the man is trying to reach him, he’s trying to reach the child but he can’t reach the child. He’s going to fall off what he’s holding on to, but he can’t reach the child.

Dr. B: In what way did it bother you originally and in what way does it bother you now. What is it bringing to mind?

J: It, the first thing that it was an automobile accident that I went to and the father couldn’t get to his kids.

J: It was in the late ‘70s, I think around 1978. It was, it was pretty hot out that day and.

J: It was in summer.

J: I don’t know, I mean I looked at it and it didn’t make any sense. It was just right there in the middle of the road, smoking and there was a pickup truck on my left. It was sitting on the shoulder with the front wheels just touching the pavement. There was a red small Ford product and it was just past the pickup, 50 feet, maybe and it was facing the opposite direction. The pickup’s this way and the car was that way. There was a woman; she was lying on the ground just outside the passenger door. It had been torn open. She was partly under the car and there were two children, a little boy and a little girl.

J: It didn’t make any sense. I got out of the car and I, there was traffic backed up and I just blocked the road to keep people out of there. I told them to get the hell out of there.

Dr. B: Yeah.

J: It was overwhelming. They were all screaming. None of these people were unconscious. They were in pain. They were all, oh, the kids were just screaming, they were calling out. The mom, she couldn’t see them, she could hear them. One was lying off in the ditch. They had all been thrown out of the vehicle and they had all been torn up.

Dr. B: When we talked about it before you said something about a bone in your hand.

J: They were calling for their mom.

Dr. B: I see.

J: And just crying and there was blood running down on their faces and it was horrible and I looked at the dad. I’ll never forget this. He’d not been thrown out of his vehicle.

J: His door had been torn open. He’d hit the steering wheel and his face had been smashed, really smashed bad.

J: It was blood. It was bubbly when he breathed.

Dr. B: I see.

J: Oh, yeah. Oh, yeah. The poor man could hear them and I went over and looked at the other guy that hit and run into them. He’d hit them head on. There wasn’t even a skid mark that you could see who had hit them. He was going as fast as his car would go.

J: He was speeding and, he went around the corner in the wrong lane and these people didn’t ever have a chance. They didn’t have a chance. This guy hit them just hard and the car flew apart and I went over to him and looked. He was an older guy. He was breathing and you could smell booze all over him. He’d been drinking a lot. There was a bottle in the car.

J: Oh yeah. Yeah he was drunk and I left him and I went back to the kids and I wanted to start putting 4x4’s over the open wounds. And I was leaning in the gravel next to this child and she was crying. Then I started to very carefully pick her up.

Dr. B: Right.

J: I looked right underneath her and I found this bone.

J: It was a piece, it was an end of a bone and I knew what it was, it was an end of a bone. My head is hurting, really hurting (grieving tearfully).

J: My head is hurting, I’m sorry.

J: Pressure, really, really bad pressure.

J: No, no.

J: There’s people watching and I’m supposed to be helping, you know, I’m supposed to be in charge and it was my accident scene and these people they needed help so badly. It was 57 miles to an ambulance.

Dr. B: Wow!

J.: And I knew it would take almost an hour to get there and I didn’t have enough medical stuff and I didn’t know where to put the bone and I didn’t know whose it was. There were three people hurt there and there was some chips and stuff I didn’t know.

thought it might be hers. And I went to the mother and she had crushed her pelvis and she’d broken both legs and both fingers were broken.

J: She was crying. It was really, really painful, her injury. The only way I knew to make the pain stop on her femur was to put on this air traction splint.

Dr. B: Right.

J: And I was scared to put it on her because of her pelvis and I thought I might kill her.

Dr. B: Yeah.

J: If I pulled the traction.

Dr. B: What a horrible thought.

J: Well yeah and I didn’t know what to do after that. She just, I just had to leave her lay there. She couldn’t see her kids because she was lying on her back and her children were behind her, but she could hear them.

Dr. B: Um, huh.

J: She was crying and the little boy he was the farthest away.

Dr. B: What’s your head feeling like now, John?: Pressure, hurts.

J: I just can’t catch my breath.

Dr. B: That’s right.

J: I got out the supplies I had and I started with the bleeding. I knew I had to get the bleeding stopped on all of them. And then I put big bandages and these big triangular things on them and on one of these bones that poked out. And then these kids they didn’t want me you know, they wanted their mom. They could see me.

J: It just broke my heart. These poor little things and what the son of a bitch had done this to them.

J: I was angry at this man for what he had done and these poor little kids. My little baby was her age too, they were close in age.

Dr. B: It was cruel.

J: Yeah, and I thought it was and then.

J: Yeah. I feel real self-conscious too.

J: I was the only one that had EMT training and I was trying to do all four of them: Oh, that poor man.

And I didn’t have enough equipment I mean, I just.

Dr. B: You felt helpless in a way.

J: No. I never really thought about it.

Dr. B: You never dealt with it.

J: I needed to do more and I couldn’t do more.

Dr. B: Um huh.

J: And the ambulance finally got there.

J: Oh, it was almost an hour before they got there because it was a volunteer ambulance. They had to all run down there and drive 40 some miles and then they weren’t that good EMTs. They just kind of wanted to shovel everybody up and there was just blood everywhere. There was just so much blood I didn’t think those kids had enough blood in them and the father, his shirt was sopped with blood. His teeth, his teeth were gone.

Dr. B: It was a mess.

J: And I kept thinking God, what if he dies or if he stops breathing. I didn’t know how to do CPR because he hadn’t anything left to support it.

Dr. B: Right, right.

J: I just knew he was going to quit breathing before we could get an airway there. I didn’t have an airway for him, but he didn’t. I just kept trying to talk to him and running back to the kids and.

J: Yeah and at the time it took forever for that damn ambulance to get there.

J: Oh my God and these people kept coming up and wanting to gawk at this shit, you know.

J: I finally told another cop who eventually arrived to tell them to get the hell out of there and if they didn’t see it they were to go and block both ends of the road. II didn’t want anybody, anybody coming up to those poor kids and the mom and dad. They weren’t something to be gawked at.

J: I didn’t have enough blankets for them, I think I only had three, yeah; I didn’t even have enough blankets for them.

J: Yeah. I don’t know. I don’t really want to cry.

Dr. B: Why?

J: We picked them up. We couldn’t get them all in the ambulance; we had to stack them because it wasn’t big enough. The kids were never unconscious. And I wanted them to stop crying.

Dr. B: So after the scene was cleared and all, what were you feeling because you must have a lot of thoughts and feelings about it there for a while.

J: Yeah and I was angry.

Husband would die.

Dr. B: Um huh.

Let’s take a coffee break shall we?

J: I hadn’t thought about it very much. I don’t like to think about it, the one.

J: When I close my eyes I can smell, I can feel that heat off the pavement and blood. Blood has a special smell.

J: It’s kind of, it’s a sickening odor and the pavement was hot, really hot and when I picture it in my mind I see my daughter who was almost a year old at the time. I see her. She had the same brown hair.

Dr. B: It brings images of your little girl to mind. Tell us more about that, please.

J: I see. I mean she didn’t look like my little girl, but that’s what I feel like is lying there, is my little baby is laying there.

J: Oh God. I probably would have wanted to hurt him in some way… I mean this little child just didn’t deserve this and.

J: It’s so sad.

J: It hurts… yeah.

J: He looks desperate, like he’s clinging to it and he is going to lose, he’s going to fall.

Dr. B: Yeah.

J: And he can’t quite touch him, he just can’t quite reach them.

J: The child is hanging on. The child is reaching. I see him reaching but they can’t touch each other, they’re separated.

J: That’s what, that’s the car, that’s the man who’s sitting in the car, to me. He’s trying to reach his babies.

Dr. B: God, he must have felt awful.

J: He was crying, too.

Dr. B: I bet he was. That’s the stuff nightmares are made of. But that was real life. Did you ever dream about that, the accident scene or did it ever come back to you any other way.

J: It came back. The time it hit me the hardest when I was connected with another case that I was involved in. And it was so sad.

J: I don’t remember. I was still at the same post. I was still stationed in the same place.

Dr. B: You need to cry, John.

J: I’m trying to stop.

J: This little girl was lying on the table, the kitchen table. She was so small. Just a little thing. And she was so quiet. She wasn’t moving.

J: She was all wet and there was stuff in her hair. And I started trying to pull things out of her hair and stuff.

J: I wanted to cry, to just bawl.

J: She did. And she was getting cold. I wanted to get mad at this mom and dad because they hadn’t watched this child. They’d let her play and she drowned in a God damn mud puddle.

J: Yes. And you couldn’t be mad because they were crying and.

J: I had to be strong. I was the only one there.

Dr. B: So you had to be strong, in spite of your grief.

J: I had to take charge. I had to do things. I had to try and interview these people and then I had to carry this poor little baby to the airplane with me.

J: I had to take her away from her dad. He didn’t want to let her go.

J: He was crying. He was holding on to her. I said I have to take her. I have to take this child with me and he wanted to keep her.

J: She was screaming and crying and wanted to keep the baby.

Dr. B: It was terrible.

J: Oh, yeah. I didn’t know what to do. He was just devastated.

Dr. B: Yeah.

that little …

Dr. B: One of the saddest things I ever saw in medical school was a child on an autopsy table. It was awful.

J: I couldn’t stand the thought of it when I was supposed to go; I told them I couldn’t get away. I’m supposed to go. I’m supposed to do those things. I’m supposed to see the case through all the way to the end. I just couldn’t see that baby cut up.

J: Oh yeah.

J: She’s … It just scared me to death. I thought my God, this is my baby here and.

J: Oh God, I called the dispatcher and I couldn’t talk to her. She thought something was wrong with me.

Dr. B: You weren’t all right. You haven’t been all right since.

J: These little kids are so helpless. I just think that somebody needed to be there protecting them. And that somebody failed.

Dr. B: That’s right.

J: I couldn’t get there fast enough for this drowned little girl to help her…And nobody knew what to do. They might have been able to save her and they didn’t even try.

Dr. B: No CPR available.

J: No, nothing. She was just lying in a puddle of water around her and on the table she was so quiet.

J: Just think of a child that’s hurt and I had to take her away from her dad.

And I wouldn’t want to let my daughter go. If something happened like that I’d want to keep her and think something good will happens and she’ll come back, you know.

Dr. B: Yeah.

J: I couldn’t, I couldn’t do that.

If someone was taking my daughter I’d have to fight.

J: I’d want to keep her so bad, to protect her from those kinds of things.

J: I had blood all over me so she knew something was wrong when I came home. It was just all over me. I didn’t even wash my hands. There was blood all over me and I had touched my face and she knew that something really bad had happened. And I just didn’t even want to talk about it except to say it was a really bad, bad, accident.

J: I just didn’t want to think about it anymore.

Dr. B: You wanted to push it out of your mind.

J: I might have. But never the whole thing. It was always.

J: I’d see my kids. I dream sometimes that my children are hurt and sometimes keeping me, like you know, your legs are heavy.

Dr. B: Right.

J: You want to get to them but I can’t get to my kids.

J: Desperate you know. I want to do something and I can’t.

J: Oh, yeah. I’d see it was like the same smell. I would even smell it in my sleep.

J: Smell that smell that you get from people bleeding, that need to have, their gasping and stuff.

J: That piece, that car.

J: The blood, the tears, the kids were crying and blood was running down their faces and keep bleeding.

J: Oh, I can see blood on them and it would be my little girl. My little girl would be there.

J: It would be Sandy (His little girl). Yeah my little girl would be there.

J: I’d wake up all sweaty and just scared really. Scared that I don’t want to let my kids go. I don’t want to let them go out by themselves.

Dr. B: Oh yeah.

J: But I know I’ve got to give them some freedom but it just scares the hell out of me if I’m not right there where I can protect them.

J: That one I cried.

J: Nobody could see me… I was holding this little baby in my arms. I didn’t want; I couldn’t put her in a body bag. I was holding her… her eyes… I was crying a little. I was trying not to cry because I didn’t want to look….

J: As I recall I just went to bed. I just didn’t want to think about it. I wanted to sleep. I just wanted.

J: I thought about that when that image about coming into the room and seeing that baby for the first time she’d have leaves and stuff in her hair.

J: Not in a long dream that I would see. I can still see the road and I would, that what I would see that in my dreams but it didn’t fit in with the mud puddle. It would just be, a dream where I would see this child and I’ve never been able to forget it. I mean, I’ve seen so much death over the year that never comes back.

Dr. B: Right. A death of a child is different.

J: Right. You know I cannot go anywhere after that to SIDS to.

Dr. B: Yeah.

Dr. B: It’s terrible. Yeah.

J: I didn’t want to, you’ve got to take the babies from the moms and dad and I just could not do that anymore.

J: Well, they’re not real frequent. It seems that they’re always there in the back of my mind. When I see a child hurt, they all of a sudden come back to me. Just like it was yesterday. In fact I think I could draw that accident scene.

Dr. B: Just like it was yesterday.

J: Yeah.

J: I see children.

J: I see children. When I am up at the hospital and I hear children crying.

Dr. B: Yeah.

J: In a room. I got to get away from it. I can’t listen to it.

Dr. B: Yeah.

J: I can’t.

Dr. B: You feel all that stress.

J: I can’t stand to be around it, it hurts.

J: I’m not sure which one it was. It’s been a while. .

J: The baby A4. Looks like a baby in a papoose like back pack.

J: She looks safe.

J: The hand. A13.

J: This is the man trying to reach out of his truck.

J: Yeah.

J: I see the man in the pick-up truck and he’s reaching, he’s reaching out for his children. And he couldn’t get out of the truck. He couldn’t get out because he was so broken up. He, his hand was reaching for them like it was that day, that afternoon. He can’t go any further. He’s going to lose; he’s going to fall back.

J: He was so scared for his kids and not himself. You know, he never asked me about himself at all. He just.

Dr. B: Not once.

J: Not once. Not once. Just where’s my babies? Where are my kids? Where’s my little girl? And it was hard to understand because of all this stuff in his mouth and I’d have to get right next to him and he could, the blood was bubbling, and you know blood makes big bubbles when it’s coming out of the mouth. But I knew what he was saying because he kept repeating the same names.

Dr. B: It’s sadness, right.

J: It’s just, it hurts to see. I know how he would feel. I know that’s.

J: It’s the kind of image where I can’t quite get through it. I can’t quite reach the goal, to give the help I need to give.

J: Oh, yeah. It takes a few minutes you know, a while before you realize where you’re at.

Dr. B: You must feel inadequate in those dreams.

J: Oh yeah. I can’t reach them. I never do reach them. My legs won’t go fast enough. I’ve gotten up and I’ve gone to look at my kids. I used to have a horrible time sleeping when my babies were less than a year.

Dr. B: Yeah.

J: Infant death, I was petrified that my kids and they would always tell me.

J: That’s a skull. That just, to me that represent danger and it represents death. You know, just a scary image.

J: It is sort of like something I see kind of hovering, you know. It’s not; it doesn’t have a face with it or people. For people its death. It’s an adult. To me it doesn’t look like a child. I don’t feel sadness when I see it.

Dr. B: It’s a lot worse to see a child die.

Plea for Patience and Tolerance:

Perhaps your brain has already been psychologically damaged by negative messages from oppressive figures. Realize that every person has both good and evil inside. Please try to activate the positive decent side of your character. Gain self-respect by resisting any impulse to hack into this web page with destructive computer viruses. Also kindly restrain from e-mailing abusive comments to other participants. Consider submitting constructive suggestions for correcting or revising what you may consider erroneous material. When challenged by new information foreign to one’s own belief system, becoming angry is understandable. Being destructive is not!

Interpreting the black and white symbolic patterns posed by a language’s alphabet (i.e. the psychophysiology of reading) enables you to peruse the minds of others whom you have never met. This amazing and scientifically ill understood body-mind activity allows one to transcend time and space. You can acquire insights into the thoughts and emotions of dead individuals whose brains have now turned to dust.

Introspection:

Inner mental life is complex and mysterious. Peering beyond the external “Shell” into the “Inner reality” can present illusive images and confusing perceptions. Most individuals conceal what is inside by presenting a social façade or persona to the world. This defensive shield may in turn obscure introspective views.

Civilized humans have the capacity for good, yet even for such positive people primitive impulses giving rise to a dark side or “Shadow” lurking within. Remember that these can be projected onto your image of others. Such mental deception can serve as a rationalization for blaming them and falsely justify aggression.

The visualization exercises in this web site can be a growth exercise to modify negative belief systems. It is challenging to learn to see with your own eyes, in order to independently judge what is true. It requires acquiring perceptual skills early in body-mind development. Everyone can learn how to reappraise irrational and superstitious viral like beliefs programmed into their brain’s hard drive by early life figures.

A child’s nervous system records biased information long before neural maturation permits independent judgment. It requires maturation for a child to stop believing erroneous viral input to ones brain’s hard drive such as: “That if I swallow a watermelon seed, which a watermelon will grow in my stomach”.

Reviewing Posttraumatic Stress Disorder (PTSD):

As indicated earlier, it may also be a challenge to weed out, rethink, and emotionally recondition severe traumatic memories. These result from stressful life experiences which result in intense fear, helplessness or horror. Under these conditions the stress specific imagery is recorded in neural memory centers more vividly than other life experiences. These records tend to intrude into daytime mental activities in a recurrent disruptive fashion - often for years.

In the initial posttraumatic period, this imagery tends to appear almost nightly in the form of recurrent “Nightmares”. These involve a recurrence of the original intense disturbing emotions linked to images depicting the trauma. In the daytime, awareness of such material may be triggered by external or internal cues that represent directly, or in symbolic form, the original stress. These can surface as intrusive distressing recollections which have the capacity to be distracting and disrupt concentration. With severe trauma they may be associated with concurrent image specific illusions and/or hallucinations.

In this disrupted body-mind state, some persistent aspects may tend to be more reasonably categorized as “Body” than “Mind”. A victim may experience confusing impulses providing internal pressure to experience stress specific body sensations and/or motor impulses. In such a state the individual may tend to feel or act as if the traumatic event were recurring. There may be hyper vigilance, irritability and an exaggerated startle response. In a more scientifically observable way, attesting to the reality of persistent biological changes, various clinical studies have detected ongoing alteration in body functions. Examples of this are investigations measuring the physiological correlates of nervous system arousal during experimental conditions, in which the victim is asked to view a photograph, or drawing pictures, bringing to mind traumatic imagery.

As a defensive inhibitory maneuver, there is often persistent avoidance of stimuli associated with the trauma and the onset of a general numbing to environmental situations. Such an individual may try to avoid conversations about the trauma or specific activities, places or people that arouse recollections. There may be inability to recall important related information and a general deadening of emotions.

Eventually, many of the disturbances tend to fade as the natural pacifying aspect of sleep reconditions the emotional linkage of the recurrent imagery. In the burned out phase, their emotional residual may be felt only occasionally in the day. At night, there may only be rare sleep disturbing dreams containing disguised symbolic representations of the original stressor. The SIS images helped him in processing PTSD material and he started feeling better and fasten the recovery processes.

Mental health clinicians vary greatly in their use or dismissal of spirituality. Overly optimistic psychotherapists, often new to the profession, tend to envision treatment strategies based upon the philosophical assumption that good can ultimately triumph over evil. In formulating treatment plans, these inexperienced therapists are prone to naively assume that their therapeutic interventions have greater potency than they actually do. They may convince themselves that, given enough time, their efforts can provide relief - even in the most extreme forms of mental suffering.

At the opposite pole, there are those that tend to be more realistic about psychotherapeutic approaches, sometimes even to the point of pessimism. These include the growing number of biologically oriented psychiatrists that conceptualize mental illness physiologically. They tend to envision therapeutic strategies in which genetics and brain chemistry override psychological, socioeconomic and cultural factors. Many modern psychiatric residency programs primarily emphasize psychopharmacology. In such intellectually restricting academic settings it would be considered ridiculous, if not unethical, to incorporate spirituality in planning treatment. To challenge such bias requires an open mind, imagination and an element of courage.

To advance in this intellectual battle, investigators and clinicians now may include in their struggle SIS theory and methodology. A brief historical review will give perspective. During World War II the need to evaluate large numbers of recruits in the military gave impetus to psychologists developing instruments for personality assessment. As an outgrowth of this the Rorschach technique gained widespread popularity. In the postwar period its stature far exceeded its virtues. As an extreme example, in some American prisons Rorschach test results were strongly weighed in determining whether or not a particular inmate would be given the death penalty.

During this era there were also exaggerated expectations regarding the effectiveness of the “talk” therapies such as psychoanalysis. Psychoanalysts were prevalent in positions of educational influence and power, especially in American medical training programs. It was hoped that psychoanalysis could even effectively treat various so-called psychosomatic conditions. Eventually the unrealistic nature of such wishful thinking became apparent. For those who were trained in psychoanalytic therapy, it was highly demoralizing to realize the theory had been vastly overrated. Furthermore, with the exception of the Jungians, psychoanalysts tended to overlook the role of spirituality and religion in an individuals’ mental functioning.

Gradually in medical schools the more scientifically oriented psychologists gained in influence. Concurrently, “objective” tests such as the MMPI became more widely accepted. Projective techniques were considered lacking in sufficient validity and reliability to be worthy of scientific inquiry. As a result, Rorschach analysis of direct and symbolic content, such as advocated by the psychoanalyst Roy Schafer, was no longer considered worthy of inclusion in training programs.

Along with these developments, therapists created other effective treatment approaches where an in-depth formulation was not of paramount importance to treatment outcome (e.g. cognitive therapy). In a more extreme extension of their roles, presently in the United States some psychologists are acquiring training in psychopharmacology and lobbying legislatures to obtain prescription privileges. This movement comes at a time when American insurance companies under managed care have dramatically restricted their coverage of diagnostic assessment. Along with the emergence of social workers as therapists, these events have tended to blur professional boundaries in the mental health field. Unfortunately, recent years have seen a growing pessimism in some circles about the cost-effectiveness of the various psychotherapies.

Against this background, therapies that emphasize spirituality have been developed by a relatively new discipline that calls themselves pastoral counselors. Historically the opportunity for their emergence was originally established by the poor results obtained by most existing therapies with addictions. For example, Alcoholics Anonymous, based upon the concept of a “Higher Power, has been more effective than non-spiritual approaches.

Of course the ancients were fully aware of the healing power of dreams and imagery. The legendary physician Asclepius championed their application, for example. His views were respected for centuries, until they were eventually suppressed by the emergence of authoritarian religions. These have moved the focus of attention away from the appreciation of subjectively experienced spirituality and encourage the faithful to seek dependency on authoritarian leaders. These leaders feed their followers with promises of relief from pain and fulfilment of wishes. They also provide an opportunity to fulfil basic needs for socialization and group involvement in an increasingly alienated world. Of course, such simplistic sugar coated medicine has little value for mature individuals who are capable of thinking for themselves. For their mesmerized followers, such omnipotent and grandiose leaders undermine responsibility for exploring and integrating subjective images and feelings - the essence of one’s humanity.

At this stage in the history of knowledge, there are an ever-growing number of scientific studies indicating that an individual’s religious life is important to health, both physically and mentally. Even more exciting are new developments in investigation such as those of Gregg Jacobs at Harvard Medical School who has published several studies on the way the brain waves change in meditation. In terms of anatomical localization, investigators such as Andrew Newberg at the University of Pennsylvania have localized a small region near the back of the brain which becomes unusually quiet during meditation and prayer. Since this region has been considered to relate to spatial orientation, it could explain the borderless spiritual communion felt by mystics in many traditions. In this new millennium it is becoming more methodologically feasible to investigate the previously intangible spiritual dimension of life.

In the July 1997 issue of SIS Journal of Projective Psychology and Mental Health, preliminary case history studies on the “Medical, Psychological and Spiritual” applications of the SIS were first published. With modesty and reverence for spirituality, we must attempt to overcome the many methodological limitations in this illusive area of inquiry. To avoid the scientific study of spirituality would be a comparable to burying one’s intellect in the cement of rigid reductionism.

Phenomenological exploration of dreams and SIS triggered imagery may be partially conceptualized against this background. The nature of the “Dreamer” must be considered and distinguished from the person’s conscious personality or ego. The natural source of imagery, affect and symbolism is spontaneous and largely beyond the sleeping individual’s control. Frequently the sensory information in dreams refers to physiological body needs (e.g. dreaming of urination when there is accentuated sensory feedback from a full bladder). Other dreams may reflect primitive drives related to sex and aggression. In medical patients pain may be experienced in the diseased area. In traumatized individuals, dreams may reflect a direct or disguised reliving of the trauma. There are many other determinants of dreams besides spiritual influences. Attempting to identify spiritual content in these is as futile as a prospector’s panning for gold in the Sahara Desert’s sand.

Spiritual dreams are precious but comparatively rare. When they are experienced, they have great healing power and can motivate the individual to acquire a sense of reverence for the Dreamer’s mystical healing power. Two examples follow: In the first instance, the Dreamer introduces a scene of the afterlife, in which a diseased grandmother spiritually visits and reassures a grieving African American adolescent girl. In the second, the Dreamer extends hope of attaining an educational goal for a severely traumatized and lonely adolescent Alaskan Native girl

Case Histories:

Both patients (first named BB and second named A) were Christian adolescent girls who had been receiving psychiatric hospital treatment for severe Major Depression associated with for suicidal ideation. Following admission they had participated in psychotherapy together. They had bonded well emotionally and were quite supportive to each other. Evaluating their dreams and responses to the SIS Booklet Images in a two-person group setting created a more open atmosphere for demonstration purposes.

Dr. B.: We’re going to hear BB’s Dream first Okay?

BB: Okay.

BB: About like three -- three days ago.

Dr. B.: Okay. Let’s hear it, please.

BB: “I was in church.

BB: And — I was in church and my grandma had died, or whatever. And so there was a part at the end of the church where you get to go up and accept Jesus as Your Savior. And I went up there and I did. And then later on that night I went to sleep. And I was dreaming that I had died, or whatever, and — I had — went up to heaven and I was trying to get into the Gates, and my Grandma was on the other side, she was inside the Paradise, but I was on the other side trying to get in and she’s just reaching out to me and I couldn’t get in. That was my dream. (The loss of a loved one often provides strong motivation for thinking about one’s own mortality and religious beliefs).

Dr. B: And how did you feel in the dream?

BB: That I wasn’t going to get to heaven, or to see my grandmother again. But then part of me felt good because I knew she was okay.

Dr. B: Yeah.

BB: It was wonderful to see her as okay.

BB: She — it — it hurt her because she wanted to see me do better and stuff. And she ended up passing away before she could see me, like, coming to an adult and see me graduate and stuff like that.

BB: I was sad, but then I didn’t really cry because I knew she was going to heaven.

Dr. B: Hm.

BB: And plus…

Dr. B: That was a comforting thought. (She received from her inner spirituality the message that her grandmother’s spirit was on a higher plane, and that she no longer suffered from her terminal cancer. From the interviewer’s perspective, the individual spirit goes on to a higher spiritual level of mystical existence after death of the physical body. While there is a loss of the physical body, the spirit continues on a different level and this can be reassuring to the grieving individual, who may have further communication via dreams, hallucinations, and SIS imagery.)

BB: Yeah. And plus it’d be — when she died it would be a better place for her.

BB: I don’t know.

Dr. B: Please try.

BB: Okay.

Dr. B: Thank you. And now we have A’s (Second patient) dream — another dream that goes on a little longer. But it’s a wonderful dream. (As with BB, this dream was reported previously in therapy.) When did you dream this dream?

A: I think the day before last night.

Dr. B: Okay. Can you tell us it, please? It’s a wonderful dream.

A: I had been shipped down into Montana, in Yellowstone, to go to long term with my little brother. And when I turned eighteen I signed my brother up for treatment — and my mom and step-dad had died. And so my biological father had full custody of me. And he ended up giving me full custody of my little brother. So I signed him up for treatment. And I worked and got enough money to move back to Fairbanks. And we stayed at my neighbor’s house, right next door to my sister. And I had gotten my Masters Degree in Montana.

A: I felt proud of myself.

Dr. B: Yes.

A: And — So I got a job in Fairbanks. And I was letting my little brother drive my car around while I was at work, with his friends as long as he didn’t drink or smoke in it.

Dr. B: She’s a good big sister (An aside comment to BB calculated for Anna’s benefit to further support the latter’s self-esteem).

And then a couple of years had past and we had moved back in with my sister and her boyfriend. And I shared a room with my little brother; of course, I wasn’t there most of the time. (An indirect acknowledgement of some incestuous sexual tension between her and brother, though denied. As will be shown later, the patient had been sexually victimized both by her father and her older brother. She thus needs to deny any overt sexuality more vigorously. Consistent with this theme in dream consciousness, next emerged symbolic sexuality in the dream by images of the brother impregnating another girl. This interpretation was not brought to the patient’s attention because it was not felt to be a suitable therapeutic setting.)

A: He’s four years younger than me.

Dr. B: Hm.

A: So he was — he didn’t really feel comfortable about being — staying in the same house as our older sister. So I bought a door lock and I gave him a key so that he could be in the room and lock the door. And I could still go in when I needed to. But my sister wouldn’t be able to; cause the door would be locked.

Dr. B: It doesn’t matter.

A; My best friend’s little sister starting going out, and stuff. And my best friend and I were okay with it. You know. They got a little too close and — so we had to hide her sister at our house when she started showing her pregnancy. And my best friend was getting kind of worried because she was seeing her sister less and less. And every time she saw her sister and — it would just be like her head, or something.

And so she came over to my house, with her older brother, and she demanded to see her sister. And just at that moment my sister came screaming up from our room. It’s happening, now. And we heard her scream.

Dr. B: Go ahead.

A: And she wanted to know what was going on with her sister. And so I told my little brother to take care of it. And my older sister told her boyfriend to take care of it so that He could be there. And — so — I don’t know. She ended up giving birth to twins. And — so me and my friend, we’re both aunts, again. And — so I bought them an apartment and they had — “M” had to get a job so that they could support the babies. And I would pop in like once a week or something and see if everything was okay. And I’d lend them money if they needed some, as long as they paid me back. That’s it.

A: That I can do whatever I want in life. Cause I’ve got my Masters Degree and full custody of my little brother.

Dr. B: I have high hopes for you. It’s a wonderful dream and predicts your future possibilities. (Again we use the dream as a vehicle for positive cognitive therapy. The fact that this dream was repeated verbatim twice supports the contention that this was a valid dream and not a confabulation. The excessive detail of this dream is consistent with the idea that this dream might also reflect a type of positive transference in which she presents a gift to her therapist. Again the time was not appropriate to make this interpretation in this artificial and tape recorded demonstration session.) Okay.

We’re going to do something else now and — can you tell BB why you liked this when you first viewed the SIS images several months ago during your first hospitalization.

A: I liked it cause — I don’t know. I liked using my imagination with the pictures that are in it.

Dr. B: Okay.

Dr. B: Yeah.

A: I think my number one favorite would be A3.

A: I see a cross, like — of both the heavenly world and the underworld.

A: I don’t know. I feel kind of happy cause in my mind it seems like both worlds are connected. And I hate seeing people using Hell against others. Like, if you’re bad, you know you’re going to go to Hell. But either way, I think, everybody goes to Heaven. Because everybody has a good inside of self. (Her response initially reflects her positive experience with Christian symbolism. However, her associations immediately lead her to the unhappy and spiritually disruptive memories of attending a fundamentalist church where the pastor’s sermons threatened hell and brimstone).

A: The second one I like most is — I don’t know. I like A27, also.

Dr. B: Tell us about what you see in A27, please.

A: I see a lot of things.

Dr. B: Hm.

A: Like on the left side there’s a guy with his head showing or something. And he looks like a lumberjack person.

Dr. B: Hm.

A: If you turn it upside down.

Dr. B: Tell us about your dad.

A: My dad? Well, I kind of look down on him because he hurt my whole family.

A: He molested my older sister, who triggered my older half brother’s mind, you know. Oh, if I do this then I’ll be just like him. And then I’ll be carrying on the real family name. So he ended up molesting me.

A: And — you know, but I kind of look up to him because he’s the only real father that I know. And I was really close to him.

A: I last saw him in ‘96.

Dr. B: Now it’s your turn BB to tell us the one that you like most? (BB had never seen the SIS booklet before).

BB: B29.

BB: I see a person, like, running into the light.

BB: It makes me — it kind of reminds me of myself, kind of.

BB: Cause most of the time I was, like, in the dark all the time.

BB: Like I didn’t really know, like, what life would bring whatever, or me. And. Like — I didn’t — I just didn’t really know myself.

Dr. B: I see.

BB: And now it’s like I’m getting to the point where I can talk — talk about things. And.

BB: Yes. And now I’m, you know, going into the light about myself. I’m getting to recognize my feelings more. (BB’s initial phase of hospitalization has been quite positive).At this stage her depression was lifting and psychotherapy had provided release from some of the bad feeling projected onto her by her mother.).

BB: The next one — well, I like B5.

people in a chair. And, like, the biggest one — it’s like the bubbles are going to the — the girl, like

she is talking at her.

Dr. B: Hm.

BB: And not with her. And it reminds me of when my mother used to talk at me instead of with me. And it would just go out of — go in one ear and out the other. And...

BB: It made my self-esteem go very low, because — it was just like some of the things that she said would — wasn’t very nice.

BB: Like — she said a lot of things to me. Like — to make me feel that my grandma’s death was my fault.

BB: Yes.

BB: She said that I really wasn’t trying to help my grandmother. When I would disobey her and not clean my room that was a stress on my grandmother.

Dr. B: I see.

BB: And it added more to her cancer.

Dr. B: Hm.

BB: She’s had it before. And it just came back.

Dr. B: That’s right.

BB: But my grandma was — but my mom was still influencing me that it was my fault.

BB: Hmmm, yeah.

Dr. B: Next we will explore the meaning of the ones that bothered the most.

Which one bothers you the most? Which one did you like the least?

A: Probably 8B.

A: I see a person with a hat on, and the light is behind. And they can’t really see anything else but themselves.

A: Depression and loneliness because there are no other people in the picture. And to me it looks like everybody is looking down on that one person.

A: Yeah.

Dr. B: Tell us about it.

A: Well, I thought that everything was my fault, especially the time when my brother molested me. I thought that it was my fault for being — for looking like my sister. And.

Dr. B: But you know different now? (In order to retain a positive fantasy relationship with a family member who is abusive, ordinarily the child accepts the blame, resulting in cognitive confusion and self-hatred. Her previous therapy has been partially helpful in correcting this distortion.)

A: Yeah.

A: I think it’s — yeah, B15.

A: I see, like, knives and stuff going at, like, some figure.

A: I don’t know. It could be a person or an animal.

A: It brings war to mind. And I feel really disturbed because I hate violence.

A: My next door neighbor he use to have a really, really bad problem with anger. And — and I was babysitting his two kids at the time and he told me to take them in the back. And I was like, okay. It’s probably just another argument, because they fought a lot. And, you know — but it didn’t sound like just another argument. And so I tried to get the kids out of the house because, I was hearing screaming and stuff and I saw that it was making them uncomfortable. And so I tried to get them out of the house. But he came and he saw me and he started yelling at me and saying that, you know, he — I couldn’t take his kids.

Dr. B: How did you feel at that point?

A: I felt scared. Because he had a knife in his hand. And he threw it at me one time.

Dr. B: Wow.

A: And it barely missed my head.

Dr. B: Wow.

A: And that — I was scared to leave because I didn’t know what he was going to do to the kids.

A: In her initial evaluation months earlier, this inkblot had triggered memories of childhood anxiety laden dreams depicting the original trauma.

A: I see two people, a man and a woman, and the woman looks scared or shocked.

A: It brings to mind my mom and my dad. Because my mom would look like that whenever he was around. And if she and I went to the store, or something, she would look really scared.

BB: B27

BB: It looks like two fetuses.

Dr. B: Uh huh.

BB: It reminds me of my older sister and me which is now dead. But like.....

BB: She died in ‘83.

BB: It makes me feel sad because — my mom, when I was born, she told me that she always thought I was a re-incarnation of my sister, because my mom says that my sister wasn’t ready to die.

BB: I was mad that my sister was gone. And then I was kind of like — I was just very — I don’t know. (This past history had been obtained when the patient was initially admitted to the hospital. Since then, little therapeutic attention had been given to this report. This oversight in the treatment plan was immediately remedied as a result of the new information concerning how threatening this was to BB. This illustrates the importance of rating responses on an anxiety-threat scale).

Dr. B: Were you — you felt very sad? Okay. Please tell us what one bothered you second most.

BB: B16

BB: It looks like an arrow going through someone’s heart.

BB: Yes.

BB: It kind of reminds me of my feelings sometimes.

BB: Like my feelings about my grandmother, my brother, and myself.

BB: Well when my grandmother died it felt like — I felt very heartbroken. This illustrates how the SIS symbolism can more readily capture the affective experience than words alone. Most languages lack sufficient words to describe the various types of human emotional suffering experiences after loss of a loved one.

BB: Yes.

BB: It was very depressing. And it was like — it just hurt.

BB: Yeah, cause my brother he’s motivation to me. He’s a big motivator to me.

BB: We’re six years apart.

BB: Yes. He’s.....

Dr. B: That’s important, that love? Okay. Did you want to say anything to A about her responses? What she saw and — what did you think about what she saw?

BB: I think that she has a creative mind. And...

Dr. B: Yes.

BB: I think that she — some of the stuff that she seen, since she’s, like, so young she shouldn’t have seen.

Dr. B: Hm. Left impressions — bad impressions that we have. Okay. And what did you think of what BB saw?

Dr. B: Hm.

A: But now that I look at it really closely I can see the heart and the arrow.

A: Yeah. And I think it’s really sad about everything that she went through. Because nobody deserves to go through any of that. And I feel kind of sad, in a way, because I still have my grandparents.

The Dreamer can provide vital information from its God- given source for healing. For those who pay attention, it can serve as a compassionate and infinitely wise inner “consultant”. These spiritual dreams need to be documented for lifetime recall by the individual through written notes, voice recording or art work. Most individuals – even those with limited intellectual ability – can decipher to a degree the direct and symbolic significance communications from this inner spiritual source. Frequently, however, psychological defenses resist the emergence of painful material. Consequently, sharing the dream with others, especially in group therapy situations, facilitates interpretation. Occasionally, exploring SIS triggered imagery can aide in this process.

BB’s joyous dream represented a spiritual visitation from her diseased grandmother, with whom she had been living. It was tremendously reassuring for BB to realize that her beloved grandmother was no longer suffering from a cancer-ravaged body. The gradual death from cancer had provided terrible visual impressions with BB. The dream also pointed to the need for cognitive therapy to correct her low self-esteem, as symbolized in the dream by her not being able to enter “Heaven”. Like too many African-American children she had no father, and so had a greater than usual need for nurturing from her mother. Instead of receiving comfort and support in her grief, however, she was met with further rejection and irrational criticism. Certain of these communication problems were depicted in her projective responses to Image B5. What was also significant was the imagery evoked by B27. This pointed out the importance of therapeutically clarifying with BB in family therapy sessions the implications of her mother’s reincarnation belief.

A’s night time message from her Dreamer provided prophetic hope. It promised that if she persevered in her therapy eventually she would be able to obtain a university degree. She could then obtain suitable employment and accomplish her goal of providing for her beloved younger brother. Like BB’s little brother, he gave her life meaning. Image A3, with its Christian symbolism, provided a religious shield in spiritual consciousness against the surfacing of traumatic memories. Their ever-present tendency to painfully surface was reflected by her responses to images B8, B15, and A31.

This particular demonstration involves the SIS II Booklet. In this Image A3 is in a monochromatic bluish gray color and the form is suggestive of a cross. For many devoted Christians this can stimulate spiritual imagery and affect in consciousness, activating healing. The image significantly contrasts with many traditional artistic representations of Christ‘s crucifixion, which are highly structured and leave little to the imagination. With abstract symbols, such as this SIS inkblot, there is an enhanced potential for the external visual stimulus to tap into the Dreamer’s deep inner well of divine spirituality. In employing this approach it must be remembered that different religions have their own unique symbols and rituals. SIS therapists must be open minded and unbiased in order to employ these for spiritual healing. It is not our role to change or convert any suffering individual’s religious orientation. Rather, we need to foster healing by optimally activating the person’s religious symbols in the therapy process. Those suffering should be encouraged to have reverence for spirituality arising spontaneously through dream imagery for themselves and their loved ones.

Tragically, in the modern world and throughout history groups have tried to destroy one another’s religious structures. A’s cultural background was partly Alaskan Native. Historically, American Christian missionaries moved into the north telling the Natives their religious symbols were Satanic. They had the power to take away their cultural rituals and dances. There are still elders in the villages that remember this era with great sadness. Now regions in the north have severe problems with alcoholism and their youth, especially the males, have the highest rate of suicide in the United States. With the advent of nuclear, biological and chemical weapons, civilization is in a relatively precarious position if the biases of narrow-minded political leaders prevail. We need to train future leaders to respect the dreams of others and their religious symbolism.

Mental health clinicians vary greatly in their use or dismissal of spirituality. Overly optimistic psychotherapists—often new to the profession—tend to envision treatment strategies based upon the philosophical assumption that good can ultimately triumph over evil. In formulating treatment plans, these inexperienced therapists are prone to naively assume that their therapeutic interventions have greater potency than they actually do. They may convince themselves that, given enough time, their efforts can provide relief - even in the most extreme forms of mental suffering.

At the opposite pole, there are those that tend to be more realistic about psychotherapeutic approaches, sometimes even to the point of pessimism. These include the growing number of biologically oriented psychiatrists that conceptualize mental illness physiologically. They tend to envision therapeutic strategies in which genetics and brain chemistry override psychological, socioeconomic and cultural factors. Many modern psychiatric residency programs primarily emphasize psychopharmacology. In such intellectually restricting academic settings it would be considered ridiculous, if not unethical, to incorporate spirituality in planning treatment. To challenge such bias requires an open mind, imagination and an element of courage.

To advance in this intellectual battle, investigators and clinicians now may include in their struggle SIS theory and methodology. A brief historical review will give perspective. During World War II the need to evaluate large numbers of recruits in the military gave impetus to psychologists developing instruments for personality assessment. As an outgrowth of this the Rorschach technique gained widespread popularity. In the postwar period its stature far exceeded its virtues. As an extreme example, in some American prisons Rorschach test results were strongly weighed in determining whether or not a particular inmate would be given the death penalty.

During this era there were also exaggerated expectations regarding the effectiveness of the “talk” therapies such as psychoanalysis. Psychoanalysts were prevalent in positions of educational influence and power, especially in American medical training programs. It was hoped that psychoanalysis could even effectively treat various so-called psychosomatic conditions. Eventually the unrealistic nature of such wishful thinking became apparent. For those who were trained in psychoanalytic therapy, it was highly demoralizing to realize the theory had been vastly overrated. Furthermore, with the exception of the Jungians, psychoanalysts tended to overlook the role of spirituality and religion in an individuals’ mental functioning. Gradually in medical schools the more scientifically oriented psychologists gained in influence. Concurrently, “objective” tests such as the MMPI became more widely accepted. Projective techniques were considered lacking in sufficient validity and reliability to be worthy of scientific inquiry. As a result, Rorschach analysis of direct and symbolic content, such as advocated by the psychoanalyst Roy Schafer, was no longer considered worthy of inclusion in training programs.

Along with these developments, therapists created other effective treatment approaches where an in-depth formulation was not of paramount importance to treatment outcome (e.g. cognitive therapy). In a more extreme extension of their roles, presently in the United States some psychologists are acquiring training in psychopharmacology and lobbying legislatures to obtain prescription privileges. This movement comes at a time when American insurance companies under managed care have dramatically restricted their coverage of diagnostic assessment. Along with the emergence of social workers as therapists, these events have tended to blur professional boundaries in the mental health field. Unfortunately, recent years have seen a growing pessimism in some circles about the cost-effectiveness of the various psychotherapies.

Against this background, therapies that emphasize spirituality have been developed by a relatively new discipline that calls themselves pastoral counselors. Historically the opportunity for their emergence was originally established by the poor results obtained by most existing therapies with addictions. For example, Alcoholics Anonymous, based upon the concept of a “Higher Power, has been more effective than non-spiritual approaches.

The cases demonstrate the application of Somatic Inkblot Series (SIS II Booklet). In the test Image A3 is in a monochromatic bluish gray color and the form is suggestive of a cross. For many devoted Christians this can stimulate spiritual imagery and affect in consciousness, activating healing. The image significantly contrasts with many traditional artistic representations of Christ’s crucifixion, which are highly structured and leave little to the imagination. With abstract symbols, such as this SIS inkblot, there is an enhanced potential for the external visual stimulus to tap into the Dreamer’s deep inner well of divine spirituality. In employing this approach it must be remembered that different religions have their own unique symbols and rituals. SIS therapists must be open minded and unbiased in order to employ these for spiritual healing. It is not our role to change or convert any suffering individual’s religious orientation. Rather, we need to foster healing by optimally activating the person’s religious symbols in the therapy process. Those suffering should be encouraged to have reference for spirituality arising spontaneously through dream imagery for themselves and their loved ones.

“Love Can Be Blind” When two people initially meet in a potential love relationship, each begins to construct an image of the other. For mature individuals who have complimentary religious/cultural backgrounds, as well as having experienced love in their family, the outlook may be positive. Yet initial impressions can be misleading, especially in hormone driven young people.

One’s mental picture of another can also be in error for a variety of non biological reasons. Theses can cause an irrational love mesmerized individual to view a potential spouse with “Rose covered glasses”. Such premarital social blindness can set the stage for an abusive marriage, which over time can lead to stress induced illness.

This presentation uses the SIS-II video to examine two clinical case histories of individuals whose erroneous premarital perceptions made them vulnerable to unsuspectingly entering a highly traumatic marriage. Eventually each experienced psychiatric and medical problems.

There is an extensive literature on the temporal relationship between life stressors and subsequent illness. In 1967 the Social Readjustment Scale was first published by Holmes and Roche to rate the relative intensity level of various stressful events in the preceding twelve months of an individual’s life. The highest stress score of one hundred was estimated to be death of one’s spouse. This phenomenological study is presented as an illustration of the stressful effects of blindly marrying a spouse having a severe Axis II Personality Disorder.

The first case involves a Russian woman who married a sociopath, who intentionally presented a false positive social image of himself. Ultimately he became homicidal and she was fortunate to survive with her life. The second involves a successful business man who married a woman who appeared normal. Unbeknown to him, she had Borderline Personality Disorder (BPD). His marriage took him to the edge of bankruptcy and for a while shattered his mental health.

For the unsuspecting bride or bridegroom, such marital mistakes involve exposure to a double stress: first the psychological death of a premarital romantic fantasy and second being traumatized. When children are involved, the magnitude of the stress can increase exponentially. Such a victim may present for evaluation in a mental health setting suffering with symptoms of Posttraumatic Stress Disorder (PTSD) in association with various types of Affective disorder. In medical clinics they can request treatment for a variety of stress related illnesses.

The two case histories will illustrate how the SIS-II video may be used as an aide during ongoing cognitive psychotherapy and psychotropic medication management. Those SIS Images designed to stimulate human content often prove particularly capable of stimulating relevant material. The projected human figures envisioned either directly or in disguised symbolic forms can provide guides to structure therapeutic interviews. These can access memories of the original positive impressions of a deceptive spouse, the loss of the fantasy relationship, and then the subsequent abuse by the marital partner.

Therapeutically processing the somatic imagery released by the anatomical SIS structure can assist. This may especially apply if there are significant stress induced somatic symptoms and/or sexual trauma. The inanimate structure capable of bringing to projective consciousness violent scenes, such as included in SIS B15 (i.e. “Knives”, Broken glass” and B21 (i.e. “Handgun firing”) may also be useful in releasing memories of suicidal and homicidal threatening situations. The same benefit can result from reviewing those SIS stimuli which depict death (i.e. A30 and B22).

This overall treatment strategy can be helpful in correcting distorted memories and PTSD nightmares of the perpetrating spouse. It can also facilitate psychotherapy designed to improve de the victim’s mood and damaged self esteem. The inclusion of techniques derived from SIS body-mind-spirit theory can enhance the therapeutic power of traditional atheistically based spiritually sterile “scientific” cognitive psychotherapy.

SIS structure denoting joy as portrayed by the figures in A9 with their beating hearts in red can be used by the therapist for suggesting that the in future relationships, love may be possible. These can provide soothing for to the painful wounds of betrayal, existential anxiety, loneliness and rage. This calming may have considerable clinical value in treating severely depressed or even psychotic individuals. It can be particularly helpful for correcting cognitively imbalanced victims experiencing suicidal/homicidal impulses in providing avenues of opportunity for introducing reality testing. Such tormented individuals need alternatives, apart from seeking relief through the analgesic path leading to death.

Spiritually oriented victims warrant special considerations, after being betrayed by a spouse. They can benefit from turning to higher spiritual powers for direction. Entirely outside their personal intelligence, this guidance usually comes in symbolic messages. These may appear in visions, night time dreams and in SIS released positive symbols. Such a transfer in faith can enhance psyche healing thereby enabling them to gradually a restore trust in humans. During this painful period, the person of the psychotherapist can represent a transitional communication bridge between the wounded soul and God.

Case I:

The first case history involves a young intelligent and musically gifted Russian woman. Early in life through introspection, she had learned to appreciate her special sensitivity to positive spiritual symbols in dreams. These played an important restorative role after she answered a California man’s advertisement for a wife. At the time, she was motivated by a romantic fantasy of having a happy married life in America. This as well as her enduring optimism perhaps clouded her judgment.

She allowed herself to become mesmerized by a sociopath who lied about the quality of their future lifestyle. In visiting Russia, he initially deceived her by playing the role of a “good man”. She had no practical way to check out his glowing descriptions about his family thousands of miles away.

For a short “Honey moon” period, she maintained her erroneous fantasy of having a loving husband. However, gradually there was a negative transformation in her impression. She observed that he tended to watch television programs presenting immature themes, sex and explicit violence. A more rapid decline in his social image took place after she became pregnant. At that time, he no longer was able to maintain a façade.

He became irritable, threatening and chose to reveal the truth about his childhood. She learned that his father had repeatedly beaten him with a belt. On one occasion his father had sadistically pushed a pin through his hand; on another he had run over him with a car. At age nine he had been had placed him in a foster family after his deranged father had threatened to shoot him. She realized that such a horrible childhood was consistent his being a violent sociopath.

For a while she tolerated verbal abuse. Then it became physical. He manifested what she believed were deviant sexual interests and accused her of being unfaithful. He insisted that she stay in the home and monitored her with hidden video cameras. When she requested a divorce, he threatened to kill her and their child. After driving them to a secluded place, he would point to a shovel saying: “That’s what I will use to bury your bodies!”

Due to her still poor English, as well as her economic dependency, she felt trapped. Eventually with the assistance of an American friend, she obtained a divorce. With her new freedom, she was able to seek professional help. She initially consulted an internist who diagnosed Crohn’s Disease. A few days later, on psychiatric examination, she was found to be suffering from PTSD.

SIS Interviews:

She was given an opportunity to view the SIS-II video at home on two occasions separated by a week: first Part A and then part B. In each instance, the therapeutic review of her responses was completed the next morning. In order to facilitate expression of PTSD projections, she was advised to first write her responses in her native language. Of course the detailed enquiry necessarily had to be done in English. Immediately after the review of each SIS stimulus, she repeated what she had seen and felt by speaking in Russian into a tape recorder. This repetition enhanced the therapeutic the SIS cognitive psychotherapy in a manner comparable to asking a victim to document in writing past traumatic experiences. It also established a record for the time when she could consult a Russian speaking therapist.

In the overall SIS-II Series, she selected B3 as the most threatening. Here she envisioned “An unreal mystical figure”. When asked to elaborate on her projective response, she indicated that the he “Was not from a good place…maybe Hell!” This was a direct symbolic reference to her demonic husband His angry facial manner was also brought to mind by other projections. Thus for example B12 was seen as “A very angry man”.

The duality in his nature between good and evil was symbolized in what she imagined SIS A17 to look like. A transcript of that portion of the interview follows:

“It is like I see part of the body…the bone…the chest…it is hard inside…Oh I see two animals who are looking at a heart…”

Patient: (P) “I am feeling bad when I look at this picture…because it is two animals…my heart…I don’t know…they not look too bad…but when I look on them…for me…seem both bad”

Next her response sequence to 18 A will be presented. It may be noted that the “Heart broken” symbolism continued:

Such threatening SIS imagery served as a trigger for releasing a flow of PTSD memories. These set the stage for further correcting her distorted cognitions and positively reorganizing their negative affect linkage.

When asked to recall how her body felt during such episodes, she described “Heart palpitations. The beating image elicited by 8 B brought to mind her past stress induced psychophysiologic symptoms, when he assaulted her. SIS 14 A brought to mind in a similar fashion her abdominal symptoms related to Crohn’s Disease.

Next an attempt will be made to show the relationship between her recollections of her stressful past reality, and her PTSD dreams, as well as their parallel with content specific SIS symbolism. Excerpts from the transcript of when she was speaking about dreaming follows:

Dream 1. “I have so many dreams…but I see exactly the person and I see action…I have to figure out in my brain what I see…I already see what exactly happens…it is like real life to me…history” (Here she indicated that some PTSD dreams closely approximate the reality of the trauma.)

Dream 2. “I saw my husband…how he push me on drugs…and he give me shots with drugs so I can’t stand up and I can’t move…and he abuse me more in my dreams than actually in real life…sometimes I saw he is a good person in my dreams”

P: “Yes”

P: “Very bad!”

Dream 3. The third dream sequence depicted to be reviewed her ex-husband’s threats to kill her and their child. He twice almost smothered her. His perverse behavior resembled “Snuff” – a sexually sadistic scenario in which the murderer strangles or smothers the victim. In terms of experiencing such a near death suffocation, her response sequence to 11 A is relevant:“I see a nose…somebody stick something in nose…it is something which can’t make me breath too good…but I can still breath because it is open.”

P: “Yes…a couple of times with a pillow on my face so I can’t breath”.

The negatively loaded symbolic dream complex follows:

P: “ I saw dream, someone’s spirit, maybe a man’s, maybe another spirit jumping in my body and I saw how he inside me and trying going into my child too, but I push him already on myself, so he hurt just me. And I saw under the skin, going around, push, like squeeze me in my stomach and chest and I can’t breathe, and I need help.

(In the PTSD dream the terror immobilized her and temporarily she could not pray.)

Next the manner in which the SIS stimulated positive spirituality will be illustrated in two SIS projections. In this connection, B8 reminded her of “The face of an angel”. In B10 she envisioned a scene as two people looking at a religious symbol depicting God’s love.

Then in further revealing her spirituality, she went on to speak about her heavenly recurrent dreams. In these she regularly experienced the healing power of calming spirituality. These would enable her to temporarily travel away from earth’s stresses. She would awake feeling restored and more able to care for her child.

“It is like I am flying. So a couple of times, in dreams, but a little bit. I am flying under water. Sometimes, it is landscapes, but lately it is water. But underneath the water I feel big, big huge castle. And it is so beautiful, and it is a little bit old fashioned. And I fly inside and I see huge, huge, mirrors. I feel like something, and I am just like flying over there, and I see beautiful, beautiful furniture…so beautiful pictures. .chandeliers…and sometimes I go down and I find, little river, or something, a creek...a little creek, but nobody is working there because it is so much, but some of them...a definitely sweet place and I found diamond rings there, and sometimes jewelry. And peace and quiet.”

Case II:

Be witched by a woman with Borderline Personality Disorder. This involved a 46 year old business man originally referred for treatment of Major Depression. During the initial evaluation it quickly became evident that he also was also suffering from PTSD.

When he married, his beautiful bride she had seemed quite loving. Little did he realize that she was concealing the external manifestations of a Borderline Personality Disorder (BPD). Her mental disorder manifested itself when she was on a winter vacation living for a short time by herself in their Arizona vacation home away. This timing was consistent with the extreme vulnerability to the stress of separation characteristically experienced by unstable individuals with BPD.

Prior to marriage, she had indicated that her European childhood had been happy. He had no opportunity to meet his future in-laws, so was readily taken in by her deception. After she began to decompensate psychologically she revealed that she had been socialized in a dysfunctional family. For the first she revealed that her mother had an extensive psychiatric history: severe mood swings, multiple suicide attempts, sexual promiscuity, and failed marriages.

As his premarital blindness was replaced by insight into the terrible reality of his mistake, he became disillusioned and depressed. It was hard for him to accept her crumbling image. Yet it was dawning on him that he had been dubbed into marrying a woman, who was like her mother. He stayed in the marriage with the unrealistic hope of marital therapy being effective and for his two girls. Eventually was able to divorce her but not before his health became impaired.

SIS Interviewing:

He selected SIS-II video A11 as the one he most “Disliked”. It reminded him of “A broken toilet”. Over time in therapy, this became a powerful referent for symbolizing painful memories about his marital life. He repeatedly referred to his marriage as like “Living in a toilet”. Speaking in an analogous way provided empathetic support. Thus he was asked: “Tell me more about your “shitty” life. Speaking in the vernacular can often be more therapeutically effective, than using “clean” socially acceptable words.

During such interviews, the therapist is advised to wait for the appropriate time for interjecting SIS symbolic hope. This strategy can serve to reinforce the correction of depression determined hopeless. For example, in viewing A5 he envisioned “A smiling man!” Such a vision can be interpreted in a hopeful manner: “What you see here indicates that your life will eventually be much happier”. Since such a hopeful comment appears to come directly from what he saw himself, it can carry significant suggestive power.

In any one session, it is essential for the therapist not to be obsessively concerned about exploring responses to the entire SIS series. If the stress related critical symbolic SIS imagery is being effectively processed, than a goal for that session has been achieved. Moreover it might prove counter therapeutic to explore other SIS stimuli. It is essential to use sound clinical judgment in order to maintain an optimal anxiety level without flooding the viewer with PTSD imagery.

Moreover, the therapist might well keep in mind that there is always the opportunity for further SIS viewing at subsequent stages in the therapy. Moreover, repeating the procedure can utilize the anxiety/threat reconditioning provided by the floral imagery.

The second most threatening SIS Image A6 was seen as “A man and a bear”. This superimposed aggressive imagery of an adult threatening “Bear” over the inkblot’s the child like “Teddy Bear” embedded structure. Here his associations led him to discuss past threatening episodes, when his ex-wife would attempt to provoke him through verbal abuse. When this failed she became physical threatening, so eventually he had to obtain a restraining order. He realized that if he responded physically, she would use this information in court to get full custody of their children. The adult “Bear” response provided a therapeutic opening for processing his rage. It enabled the interviewer to bring reality testing for coping with and cognitively redirecting his homicidal impulses.

The third that bothered him was A2 visualized as “A flower over a tunnel”. Historically the “Flower” represented his beautiful bride. The tunnel symbolized his painful passage having fallen from wedding bliss to the terrible abusive world of his marriage.

A few other illustrative responses will be briefly reviewed:

A3: “A bleeding heart – pulled out by the roots!” This portrayed in body language his “Broken heart” and depressive core.

A 4: “A partially opened or damaged suitcase!” This symbolized his damaged masculine self concept.

A 5: “A human stomach…dead”. Prior to treatment he was suicidal as well as suffering from stress induced anorexia. The imagery denotes both aspects of his inner world.

B 1: “A fist holding a dead cockroach!” This relates to residual memories of his homicidal rages experienced consciously and in murderous dreams. Prior to treatment, he had been strongly tempted to act out his aggressive fantasies towards the men who betrayed him.

B 2: “A Devil’s face”. Within himself, this related to what he considered to be his own “evil” homicidal daytime impulses, as well as his violent uninhibited dreams. In his interpersonal world, it symbolized the “Devil” like behavior of his sexually promiscuous wife and his former so-called friends.

B 3: “Two men with a woman trying to lead them into Hell!” This symbolized the above mentioned seduction scene. He was tortured at night by recurrent PTSD dreams of imagery depicting his wife’s sexual encounters. She had taunted him with vivid recounting of her promiscuous acting out. .

B 4: “Being with two faces…the face behind a false face”. This depicted his ex-wife both as a loving wife and then as a “witch”.

B15: “Knives flying at a woman”. This denoted homicidal impulses that had been directed towards his ex-wife.

Two final response sequences warrant brief review because of their positive spiritual and philosophical connotations: B16 was seen to represent “Hummingbirds over a sacred heart”. This symbolism opened the subject of his strong religious faith. As his marriage failed, he recalled that it was only “Through prayer and trust in God” that he was able to carry on. This loving image was supported in spiritual based psychotherapy.

The second relevant SIS response which enabled the interviewer to inject hope, as a psychological antidote for his periodic bouts of hopeless was evoked by B19. This was seen realistically, as depicting “Sperm entering egg”. Afterwards his depressive inner cry was projected into the SIS stimulated symbolism as “The broken heart of life”. After repeated review of this imagery in cognitive psychotherapy, he became convinced that there was “A light at the end of the tunnel”.

Eskimos have several words to describe snow conditions. When something is important in a particular culture usually the descriptive aspects of this lead to specific unique words. In contrast to such utilitarian linguistic specificity, the English language is limited in existing terms to communicate emotions. Critics have viewed the British in the stereo typed image as emotionally repressed individuals, with limited empathetic skills. Historically it may have made the original British military immune to the suffering that they sometimes inflicted throughout the world.

In spite of such inherent language limitations, the traumatized victims in this phenomenological case history study were able to effectively express their stressful experiences. This was facilitated by the SIS stimulated symbolism which provided an additional communication vehicle. The word pictures that they envisioned to describe their visual responses having the highest negative emotional valence were particularly effective.

For example, in selecting B3 as the most threatening scene, the immigrant woman symbolically was able to communicate the terrible reality of her stressful marriage. It may be recalled that her sociopath husband was portrayed as “A figure from Hell”. In discussing this, she was able to cognitively reorganize her memories and feelings about her marital trauma. With empathetic support, she was then able to grieve the loss of the premarital fantasies, express her PTSD feelings and then accept positive suggestions regarding her future life in America.

The second case involved a middle aged man who was successful in business but not in his personal life. Like men in western culture, he imagined it to be a weakness leaning on a psychotherapist. The SIS stimulated symbolism provided insight for him. He realized the value therapeutically of speaking in symbolic language, including that associated with exploring dream symbols. Imagining A11 to be “A broken toilet” without any such SIS structural reality for him was convincing (i.e. “Seeing is believing.”).

The authorities who publish English language dictionaries might well consider the adoption of new descriptive words to communicate emotions. Evolving from the Russian emigrant woman’s most threatening SIS response, one might coin the word to describe a sociopath spouse as “Fig hell”. Consistent with the business man’s anguish, one might coin the word “Britoil” to describe the subjective anguish of a being married to a spouse with BPD. Of course realistically, at this time linguists are far from creating building a universal emotionally rich language.

SIS stimulated symbolic imagery can provide an important communication aide in clinical interviews where translation issues exist. Even though the Russian woman’s English was limited, she expressed considerable appreciation for her rapid relief following the SIS intervention. It helped to reorganize her traumatic memories and emotions by first exploring the significance of a SIS stimulated responses, and then second, this help was reinforced by immediately afterwards exploring the significance of her symbolically related dreams. For example, she had horrible memories of her husband’s attempts to smother her. When she was able to communicate through the SIS “hole in the nose” symbolism projected in relation to A11 and then further in symbolically related “spirit man” assault dreams, therapeutic efficacy was maximized.

Just as the business man was reluctant prior to SIS symbolic interpretation to communicate his inner cry, in most cultures there still exist emotional denial and repression. From an early age children are taught that it is often better to suffer in silence, than express feelings. Even mental health professionals are subject to such pressures. They are often pressured to avoid revealing the true extent of epidemiologic statistics revealing high rates of psychiatric morbidity worldwide.

Researchers and clinicians who elect to use projective inkblot technique are subjected to similar pressures. With the Rorschach, it is scientifically scandalous to witness the extent that clinicians rely on scoring systems that totally ignore emotionally charged symbolic content. While such approaches have a measure of diagnostic merit and appear to be mathematically sound through documentation with statistical norms, they represent a form of professional perceptual blindness. The clinician does not have to feel the empathetic suffering reading numbers and may feel smug in the erroneous bias that analyzing inkblot symbols is scientifically invalid. Their ethics are highly questionable and their intellectual crime is tantamount to real criminality. Vast sums of private and public health money are wasted by clinicians and computer companies who provide their emotionally sanitized sterile data.

Researchers and clinicians who choose to use the various forms of the SIS instrumentation must be prepared for some degree of inhibitory pressure from within themselves as well as from others. In attempting to conceptualize this most complex process, the following model is proposed. In regard to the former, the interviewer may have to cope with personal professional biases. Certain of these may stem from dogmatic educators who may have advocated Rorschach scoring systems, which ignore projection.

In terms of counter transference issues, those who enter the mental health field often have their own unresolved issues. Marital discordant images in the therapist’s brain memory bank may well distort perception of SIS human content. Occupational exposure to PTSD imagery from treating trauma victims may be quiet analogous to acquiring a computer virus. For those who fail to maintain empathetic but still safe professional psychological boundaries, this material can be potentially neurologically toxic.

Consider the situation when the business man was projecting the response “broken toilet” .When the interviewer concurrently looks at such a SIS stimulus, the process is complex. There is a fusion in visual consciousness between the viewer’s own idiosyncratically determined vision and of the reality based SIS norms. This then becomes superimposed on imagery projected by the traumatized victim. This creates a situation which is analogous to both viewers sharing a “nightmare”. While this has many empathetic advantages, it can be stressful.

Apart from the multiple clinical uses of SIS technology, there would appear to be applications in the field of premarital screening. Behavioral scientists and marital counselors know much more than in the last century. In western culture when cowboy films were first made in Hollywood, the plots were relatively simple. The audience knew who the “good guys” were on the basis of clear-cut visual cues. The hero usually might wear a white hat the villain a black one. At the end of the movie the hero usually romantically connected with a beautiful woman. Yet the high divorce rate in Hollywood films stars was quite inconsistent with this simplistic fantasy.

In modern movies it is often unclear who represented “good” characters in a film and who depicted “evil”. Now there is a tendency to bring audiences into theatre be presenting plots in which negative characters are portrayed as worthy of emulation. Rarely is a married couple is presented in a wholesome and loving fashion. Now American films seduce their audience with scenes of explicit sex and vivid violence.

They pander to the baser fantasies of mass television audiences, ignoring the positive spiritual aspects of marriage. Habitual exposure media portraying the dark side of human nature can negatively program day time fantasies, SIS inkblot imagery and dreams.

Entering a committed marital relationship should not be taken lightly or on impulse. In western cultures, with their over emphasis on personal freedom, this can lead to tragic mistakes. Divorce rates are incredibly high, as is the extent of psychological damage for children involved. To prevent such tragedies some futuristic planers advocate the unpopular idea of requiring licenses to have children. In the United States, this would pose a major financial threat to entrepreneurs of the expanding private prison industry.

Some cultures take the sensible approach of incorporating premarital input from responsible family members, religious authorities, or a “matchmaker”. With the advent of long distance travel, special premarital judgment issues arise. Individuals, such as those presented cannot always benefit from the reality testing that comes from meeting with prospective in laws. A consultant utilizing SIS body-mind-spirit insights perhaps might have thrown illumination on the passions of their “Blind love”.

Although not formally recognized in any existing diagnostic manual, "Body Phobia" represents a clinically definable and treatable condition. In 1976 it first occurred to me that this symptom pattern might possibly be worthy of formal recognition. At that time a small series of case studies were initiated.

For illustration purposes one will be outlined. It utilized an early 12-card form of the SIS called "A Projective Test of Body Awareness". It involved a 29-year old professional engineer who had initially been referred by his family physician for treatment of depression. During the course of his evaluation, it was noted that a major stressor was his fear of losing his wife. Their marital relationship was characterized by communication conflicts at all levels.

In rating his responses in a hierarchy of threat, he selected Card 2 as most threatening. He initially had responded: "A woman with a big mouth...the black is the hair...When elaborating further; he quickly became angry and felt like tearing up the card. He revealed that it strongly reminded him of his mother's highly critical nature and the verbal abuse he suffered as a child. Eventually he became tearful as the projective scene activated painful emotions associated with these memories.

Initially it seemed problematic to determine the mental mechanisms by which this oral imagery got transferred or projected onto the image of his wife's body. It was partially clarified as a result a subsequent interview with a female member of the treatment team. He reluctantly reported to me that he did not feel comfortable in talking to her. The reason was that he could not take his attention off her mouth. He was embarrassed and puzzled to admit that the therapist's lips resembled his mother's. The treatment team then realized that this distorted transference reaction was partially mediated through symbolic body imagery.

The threatening nature of this symbolism was also evident in his selecting Card 10 as the next most upsetting one. Consistent with the above outlined transference hypothesis, he imagined seeing the following scene: "Lips and pictures taken by the subject from the air (referring to the lower aspect of the card)".

Here it is evident that initially the threatening maternal oral image intruded upon conscious awareness. This triggered psychological defenses of spatial withdrawal enabling his mentally distancing from unresolved childhood PTSD memories of verbal abuse. Focusing on the SIS inkblot as "a photo" taken from a great distance facilitated the repressive perceptual inhibition and resultant threat reduction.

The third most emotionally arousing situation involved his viewing Card 4. Once again he became quite disturbed in visualizing imagery of a "woman" with its concomitant traumatic memories. This additional projective clue signified a new evident response pattern.

At this point in the evaluation, it seemed that for him maternal originated female body symbolism was capable of stimulating confused memories of love-eroticism- fear-hate etc. These had strongly shaped his lifelong perceptions especially distorting his interaction with females.

As might be expected some of this confusion had been historically transferred of the developmental years to his perception of his own body. Consistent with this projection onto his own body gestalt, his response to the upper object in Card 4 was "Penis". This abnormal visualization in close SIS proximity to potentially erotic arousing female imagery reflected his heterosexual phallic dysphoria.

His high degree of ambivalence about genital sexuality was illustrated by his response to an original SIS cards which clearly depicted the outline of the human body with reddish lung-like internal organs and a sexually ambiguous pelvic area.

Clinical trials indicated that it simply had too much structure to effectively serve as a projective stimulus. Most viewers perceived it as "The outline of a man's body showing lungs". For historical background interest, it is noteworthy that only a small minority perceptually inhibited the somatic content and projected other than human or anatomical responses. All suffered from severe conversion pain syndromes now categorized in modern diagnostic nomenclature as Somatization Disorder.

This man responded as follows: "A man...also the picture of the vagina (pointing to the pelvic region)...and a Penis (Pointing to the white background between the lung-like objects in the chest). Here it is noteworthy that an image of the vagina first intruded into projective awareness. This response indicated that his negative feelings about a woman's oral region had been displaced downwards to the female pelvic region. It was understandable that vaginal intercourse with his wife was associated with more emotional pain than pleasure.

Lastly, it might be noted that in a similar fashion as his response to Card 4, visualizing a "Penis" in the white background between the lungs like organ representations was highly abnormal. It provided additional projective evidence of phallic dysphoria,

Overall in analyzing the significance of the above outlined sexually ambivalent imagery it was hypothesized that he may have primarily identified with his aggressive mother's female body. Thus it appeared that the characteristics projected onto his own body gestalt during psychosexual development may have been unduly bisexual.

Treatment Plan:

These projective data were helpful in developing a comprehensive multidimensional treatment plan. This necessarily included antidepressant medication, cognitive psychotherapy, couple psychotherapy and sexual counseling. The additional dimension to be presently illustrated was behavior therapy.

To set the stage for the latter, he received four separate training sessions in Jacobson relaxation. When he demonstrated relative competence with this procedure desensitization sessions were scheduled. In the initial clinical trial, after inducing Jacobson relaxation, the SIS cards were exposed to him by presenting them in an ascending order of threat. Initially the viewing time of 5 seconds was used followed by a relaxation period of 20 seconds.

An attempt at measuring his level of arousal was made by asking him to use a subjective scale as follows: This ranged from 0 representing the psyche condition of feeling free of emotional discomfort to 100 - the greatest dysphoria ever remembered. In the initial phase, he rated his feelings as O. In viewing the 12 card series his arousal level gradually rose to an estimated rating of 20­ to 25 seconds. However, with the last one (Card 2) his rating jumped to 50.

After a five-minute relaxation period the procedure was repeated but in a modified fashion by increasing both the exposure time and the relaxation period to 30 seconds. Also, he was given the opportunity of rejecting any card before 30 seconds, if the viewing proved too upsetting. This time his arousal level only reached 20. However, to accomplish this, he rejected Cards 2 and 5, after only brief exposure.

One week later the above procedure was repeated with a further modification. On this occasion he was instructed to view each SIS inkblot but only to the degree of sensing some minor degree of arousal. Under these desensitization conditions, he rated all cards as 0 with the exceptions of Card 5 (15-25), Card 4 (10-15) and Card 2 (0-10).

The next week the procedure was repeated for a final desensitization treatment session. By this time he was relatively comfortable in viewing all cards.

Discussion:

Clinically this behavioral therapy was associated with reduction in his anatomical image dysphoria. Moreover, there was a temporal correlation with improvement in his psychological and sexual intimacy with his wife. Consequently, it appeared that he had benefited from this SIS assisted behavioral therapy. Of course, in such a multidimensional complex treatment program it is virtually impossible to sort out efficacy for one modality. Clearly more sophisticated research designs are required to follow the encouraging clinical leads evolving such pilot studies.

In contemplating future investigations, it might be helpful to conceptualize further about the possible mental mechanisms underlying Body Phobia Disorder. During critical periods of psychosexual development, it appears that childhood exposure to stressful situations can distort anatomical imagery. In this condition, the threat primarily involves exposure to sensations and emotionally charged images of the body, rather than external physical objects. The resultant concomitant affect can strongly shape perception and cognition, as well as ultimately behavior. Depending upon the individual's genetic diathesis, this sequence can play a major underlying psychophysiologic role in symptom formation including sexuality.

An example of this complex process was presented. The subject had a childhood history involving a relatively weak father figure, exposure to a verbally abusive mother and resultant distortions in body imagery. Eventually in his marriage, these played an underlying role in his multiple communication and sexual problems. The presenting problem as labeled by his family physician was "Major Depression," a medically valid symptom complex and socially acceptable label for seeking therapy. However, it turned out to be much more complex. Apart from being clinically depressed, on the basis of the original SIS assessment, it appeared that problems related to sexuality needed to be resolved.

Consistent with such complexity, evaluators of SIS anatomical responses are advised to keep in mind the following principle. Distorted body image affect and its cognitive misinterpretation, not only can relate to the suffering person's own body gestalt, but also that of psychologically significant others. This is essentially a "dehumanizing" conceptual model. During extreme psychological stress in childhood, anxiety reducing dissociative defenses becomes activated. In such situation, the child may sense leaving the body only to view it from an imaginary safer distance. Frequently victims may perceive their perpetrator's body in a concrete and primitive manner. Such distortions as illustrated in the above case study can underlay a variety of clinical problems. One involves the victim's tendency to sexually identifying with the perpetrator's body gestalt.

Historically, conceptualizing about such cases provided my original insights into the importance determining the original somatic focus of projected anatomical responses. These not only can reflect altered awareness levels for the assessed individual's own body but also that of other psychologically significant people. Frequently the detailed enquiry will throw light on the image’s original reference. Sometimes for clarification purposes other techniques should be employed to clarify the root source. With children sand tray with figurines and art therapy involving human figure drawings can assist in the interpretative process. Other approaches include verbal association tests with key anatomical words, analyzing the body symbolism in dream imagery, and as an additional example, measuring organ specific physiologic activity as it relates to sensory feedback awareness.

Finally, from the historical standpoint, it is noteworthy that this early work also established the importance of establishing an operational plan utilizing projective data reflecting the hierarchy of organ dysphoria. This facilitates the introduction of a SIS behavioral therapy program that may provide additional therapeutic potency.

After reading about the above quotation describing a suicidal youth’s “obsession” with death, are you beginning to feel a little anxious? As a thinking member of the Homo sapiens species, with a time limited body, your emotional discomfort is understandable. It means that your optic nerves are transmitting neural impulses containing language symbols to your brain’s visual areas. This is presently enabling your central nervous system to interact with your various memory pathways. Remarkably enough, in some mysterious body-mind-spirit realm, you may begin to “think’. The subject involves SIS material that even experienced mental health professionals may find anxiety provoking. After all, epidemiologic studies have always indicated that our profession has high rates of suicide.

Having the ability and opportunity to think about the subject of death is both good news and bad news for you! The former is that you are in the minority of humans with sufficient neural endowment and education to cognitively process complex symbolic information. The latter is that you will be visually exposed to potentially emotionally upsetting SIS imagery projected by psychiatrically hospitalized suicidal/ homicidal Alaskan Native males.

While this should stimulate the cognitive centers in your brain, it can arouse secondary empathetic pain in your heart. Moreover, as you read this article it may also stimulate you to think about your own mortality. In 1973, an anthropological professor of mine, Ernest Becker wrote a Pulitzer Prize winning book entitled The Denial of Death. His thesis was that apart from employing reassuring religious doctrine, most individuals use the mental mechanism of denial in philosophically contemplating their body’s ultimate fate By contrast, like the above cited suicidal youth, many mentally disturbed Alaskan natives are preoccupied with their death.

As a clinically relevant background, perhaps it might prove of interest to briefly review the special historical, cultural and socioeconomic background features of Alaska. It was purchased from Russia in 1857 for approximately seven million dollars. At the time, most Americans considered this an outlandish price in labeling it as “Seward’s Folly”. It has turned out to be just the opposite since the state is a major supplier of natural resources.

Unfortunately these developments have not always benefited Alaskan Natives. Starting with the Russian occupation foreigners began imposing their values and undermining those of the Alaskan natives. For example, the newly acquired territory was divided up by the various Christian churches. The authoritarian missionaries, priests and educators then became the powerful figures in the remote communities. They taught the children that their native religion was based upon superstition and “The work of the Devil!”

As the acculturation experience shattered existing related support systems and the integrity of family, a series of predictable public health problems resulted. In schools, children were informed by the outsiders that their difficulties were due to their inferior culture. Moreover, they were punished for speaking in their native language. Eventually the acculturation stress caused them to self medicate with alcohol. In some northern villages, upwards of sixty percent of infants born show evidence of fetal alcohol induced organic brain impairment. Adolescent Alaskan native males have the highest rate of suicide in the United States, a country where someone suicides every twenty minutes.

Case Studies of Suicide Survivors:

Case I:

The first is a 31 year Alaskan Native who was entered marital counseling with his wife. He had been intermittently suicidal since childhood. When he completed the SIS-II booklet, a flood of emotionally painful traumatic memories surfaced.

In rating the SIS responses for anxiety/threat, he selected 4A as most threatening. Here he split the gestalt of the figure. He projected a childhood memory on the left portion as himself. On the right, he visualized an image of his “Monster dad”.

In the detailed enquiry with great anguish he indicated that the latter reminded him of his abusive “Birth Dad”. He gave the following associations: “He always beat me up…I was so small and he was so huge…I really felt inferior!” At seven years old he was placed in a foster home to protect him from his biologic parents. During this period he had Posttraumatic Stress Disorder (PTSD) dreams reliving the earlier series of traumas. To him the SIS stimulated image of the “Monster dad” brought to mind his childhood PTSD dream symbols.

He selected SIS B15 as the second most upsetting one. He imagined this to represent “A window that cuts my arm!” This brought memories back of an earlier suicide attempt. Because of extensive blood loss, this had almost succeeded. A large scar on his right wrist was consistent with his story. At that time, he was under the influence of alcohol. He had gone into a jealous rage, triggered by learning that his wife had an affair with a Caucasian oilfield worker. She viewed him with a better economic future and more socially powerful, hence more sexually arousing.

The third most troublesome SIS inkblot was B22. He indicated that this reminded him of “Evil spirits!” It brought to mind “The enemy trying to put dirty thoughts into his head at night” and “Dirty pornographic movies that I replay in my mind ” He indicated that when he had trouble finding meaningful employment as a teenager, he got money as a male prostitute from pedophiliac Alaskan tourists.

Next his responses to the three SIS inkblots that evoked positive feeling will be reviewed. At the top of the list was A6 which he saw as “A kind boy,” He gave associations which reflected childhood wish fulfillment fantasies and day dreams of having a close relationship with his father. However in the interview, he quickly reverted to negative memories about his father: “He never provided me a father image…sometimes I get sad and cry thinking about him but I cannot raise him from the dead.”

His next favorite was A10.This brought back fond memories of “Looking through the rear window of my 1976 Chevy Monza”. Initially his emotions were positive when recalling fun times with the car. However, they soon became negative as he remembered eventually losing the vehicle when he could no longer compete with younger native male prostitutes.

His third favorite SIS stimulated projective scene was evoked with A9. He imagined it to represent himself happily dancing with his wife.

Certain other responses to the SIS-II booklet provide a projective window for revealing the past mental interplay between his intense suicidal and homicidal impulses:

A15: “My kneecap dislocated”. (He had sustained multiple severe injuries from placing himself at high risk self injurious behaviors).

Case II:

The second case involves a seventeen year adolescent (JF) who reported having an obsession with death. He was admitted to a psychiatric hospital because of severe suicidal ideation. Like the older native man discussed, he too had a history of severe abuse as a child.

In viewing the SIS-II Video, he rated A30 as the most upsetting inkblot. It reminded him of the past: “My mother when she is pissed at someone”. She suffered from severe mood swings and rage reactions.

The next most threatening was A31. This stimulated memories of stressful scenes of his parents fighting. The third most disturbing imagery was evoked by A13. Here he saw “A hand and arm area with a cut on it.” He said that the scene was “Very scary!’. It triggered memories of a few years earlier when he had first tried to kill himself.

His three favorite SIS inkblot were as follows:

B28: “A mother hugging her child.” It reminded him of the few times that his mother was able to act in a loving fashion.

A6: “Me at age eight.” Here he envisioned the background figure as “A teddy bear.” However, his positive emotions quickly left. He soon was speaking about memories of when his mother was highly abusive.

Certain of the other SIS inkblots evoked material relative to his suicidal history. These were as follows:

A2: “Blood on the floor when I was in the third grade.” In describing this scene, he became very emotionally upset: “My father called me at night and told to immediately run and get the police. When I was running downstairs to go outside I looked and saw my mother with a knife cutting deep wounds into her wrist. Blood was squirting out onto her arms and legs. There was a puddle on the floor. It was very, very frightening.” Following this he had recurrent anxiety laden PTSD dreams reflecting in content and affect his SIS triggered imagery.

A7: “”A neon signs for a night club.” Here he failed to visualize a woman’s gestalt because of his PTSD induced aversion to female body imagery.

A10: “An evil person!” His self concept from irrationally blaming himself as a child for his mother’s mood disorder.

A16: “A crying person.” This depicted himself at age eight, sad, alone and crying by himself at night.

A17: “A couple of dragons devouring a heart!” A horrible scene consistent with the symbols in his PTSD dreams.

A20: “An upside down person with huge feet.” Like the older Native man, he too had frequently engaged in high risk suicidal like behavior. Shortly before hospitalization while intoxicated driving a vehicle at high speed, he had almost been killed.

B1: “All consuming flames that consume everything.” This reminded him how once had almost set his bedroom on fire.

B2: “A headless person that has been ripped apart!” This reminded him of his violent video and computer games.

B15: “A shattered window.” This brought to mind the shattered window of the truck that he recently had rolled.

Case III:

The third case involved a youth who had been hospitalized because of serious suicidal ideation. He had a long history of psychological and physical abuse by his stepfather. He suffered from related PTSD nightmares and rage reactions.

In viewing the SIS-II video he selected A25 as the most threatening inkblot. Here he conjured up an image of “A large predator fish or animal which had the capacity to hurt you!” It brought to mind traumatic memories of his abusive step father.

The second most threatening SIS inkblot was A18. This was simply too anxiety provoking for the traumatic memory to fully register in conscious awareness. The best he could do was report “It is the shape that bothers me.” He was clearly quite disturbed in seeing it again in the detailed enquiry.

The third most threatening SIS inkblot was B3. He said that this resembled “A mask!” His associations revealed a degree of paranoid ideation: “I do not like faceless people and not being able to see their eyes!”

Next attention will be directed to certain other responses which appeared to have clinical significance:

A3: “A bomb blowing up…maybe a pipe bomb.” When asked to expand on this he indicated that it reminded him of “A terrorist attack.” He appeared to be fascinated by news accounts of terrorism. He claimed that he had just read the biography of the mail bomber Ted Kozinski. He reported that frequently when he felt angry, that he fantasized about blowing up people. He quickly added “I would never do it!” His response revealed the close approximation in his mind between suicidal and homicidal impulses. Troubled and angry young people like him like could be vulnerable to terrorist propaganda. If they were living in certain war torn cultures, possibly they could easily be manipulated into becoming “suicidal bombers”.

A31: He saw “Two people yelling at each other with a red haze in the head area.” Here is significant that he focused on the “Red” This was consistent with the rage in his parent’s long term marital battles. When their anger was directed to him, he would feel alternatively fear, rage and then sadness.

B7: He saw “A gas mask,” In speaking about this he revealed a series of fantasies about being a warrior, soldier etc and participating in war. These thoughts were constantly activated when he played electronic war games which can inflame aggressive impulses (Cassell and Dubey, 1998).

B19: was seen as “A broken heart trying to catch the little hearts in tentacles.” Here the symbolism reflects a mixture between his sad suicidal feelings and his violent homicidal aggressive ones. In speaking about this impulse battle he emphasized that he no longer could cry. The last time that he had this healthy release for his pent up frustrations was at age seven after his step father had abused him. Since this traumatic event, he had dissociated himself from his PTSD pain. While this defense mechanism protected him from inner cry, over time it provided the fuel for his destructive fantasy life.

B27: was seen to represent “Two twins in their mother’s womb…one bad and one good.” Here the symbolism depicted the two aspects of his evolving adolescent personality. Clearly the “Bad” reflected his destructive side.

Case IV:

The last illustrative case involved a man who had several violent features in common with the first case. He had been episodically suicidal and had survived two serious over doses. He also had intermittent jealous rage reactions related to his wife’s infidelity and murderous impulses to kill her.

Certain SIS II Booklet responses captured his suicidal/homicidal ideation:

A4: “A mad cat!” This represented the projection of his own rage onto the image of a cat. Prior to hospitalization, when raging about his wife’s unfaithfulness he had killed cats.

A7: “A mad woman teacher with an apple!” he claimed that his wife had anger problems and was threatening him.

A27: “A woman’s breast being cut by glass!” Here again the symbolism depicts the murderous impulses that he had chosen to deny, when questioned as part of a standard mental status examination.

Unfortunately after discharge he failed to have follow-up treatment. Eventually he killed her. Three years later when incarcerated for murder, reflecting his anger and regret for having acted on his unreported homicidal impulses, he selected the scene evoked by B15 as the one that bothered him the most. It may be recalled that this particular stimulus array was designed to evoke violent fantasies. In the retest situation, he imagined this to represent “Knives with broken glass!”

In recent years American mental health practitioners have seen more violent behavior. There appears to be almost an infectious and theatrical quality at times with violence. This applies to both suicidal and homicidal violent behavior. The former has been studied under the name “suicide contagion” (Gould and Davidson 1988, Davidson and Gould 1989). This refers to the process by which exposure to the suicide or suicidal behavior of one or more person influences other to attempt or commit suicide. The effect appears to be strongest in adolescents (Phillips and Carstenson 1988, Gould et al, 1990).

An example of the theatrical quality of violence occurred in one northern village recently when an adolescent Alaskan Native youth set the stage for his murdering the school principal. He created an audience by boasting in advance to his peers. He informed them exactly where, when and how he was going to commit the murder. On the specified day, he had an appreciative audience of youths when he shot the victim.

As is frequently the case in the United States, his photograph and life story were widely circulated in the media. Since murderers have the highest status in any criminal system, this immediately made him a hero with his peers. No doubt the publicity had some economic value to the owners of the various media enterprises, though unfortunately, it had the potential for educating others concerning the status value of “Copy cat murder”!

It is amazing how some adolescents can impulsively kill, without an ounce of empathy for their victim. Several years ago, I evaluated such a cold blooded youth. The crime scene involved him being in the back of a taxi with his peers. When the driver wanted to get paid a few dollars for the ride, he put a gun to the back of his head. Reportedly the terrified victim begged for his life pleading: “Don’t shoot! I’m a married man with a wife and children!” The youth shot him! During psychiatric examination he denied remorse.

Sometimes adolescents murder and then kill themselves. American Indian adolescents who live on reservations have comparable high rates of violence as their Alaskan counterparts. Recently such a Minnesota youth went on a school shooting spree. This mass murderer watched a popular movie which provided the format for the “copy cat” violence. While the hero in this film served as a role model, this also points up to the infectious quality of aggression.

The teenager had communicated significant suicidal/homicidal ideation to certain interested peers through internet e-mail. Youth who are experiencing suicidal/homicidal impulses now can share and mutually fuel their violent fantasies through internet Blog groups as well. The technology has also given rise to a new form of abuse referred to as cyber-bullying. Adolescents are particularly vulnerable to this and there are now Web resources for those victimized (e.g. www.bullying.org and www.netbullies.com).

American surveys reveal that a high number of young people report having violent fantasies. Yet most mass murders are not committed by adolescents in minority groups. If there is a common denominator in epidemiologic terms, they are much more likely to be perpetrated on society by humans with male gonads.

Before digressing much further, a brief review historically will be presented concerning how the SIS conceptually evolved as a projective technique for assessing violent impulses. The background is presented in my book Body Symbolism (Cassell, 1980). The original research began in 1959 with a clinical investigation of the body image problems in women with excessive facial hair (Hirsutism). It became apparent that there was a need for alternative assessment techniques, apart from standard interviews. Projective techniques appeared to have particular promise for investigating the subjective manner, whereby somatic symptoms are experienced in various medical disorders.

This led me to working with the Seymour Fisher, who in association with Sidney Cleveland had originally developed two Rorschach measures of body awareness: the Barrier and Penetration Scores (Fisher and Cleveland, 1958). In examining Rorschach responses, the possibility presented itself that certain anatomical responses might reflect somatic symptom related health concerns. As an outgrowth of this, I created the Body Interior Awareness Index (Cassell, 1964) and employed this conceptualization in subsequent studies (Cassell, 965, 1969, 1971, 1972).

During this early period of introduction, I observed that many students at Syracuse University projected broken, mutilated and violated anatomical responses. In 1962 I began consulting in the student health infirmary at the university. Consequently I became familiar with their many stressors, including the ongoing Vietnam conflict. In addition, I had the opportunity working with George Stern a social psychologist in conducting health surveys revealing high rates of psychological morbidity. I realized that it was a mistake to solely relate their pathological anatomical responses to body image disturbances and medical symptoms. It seemed more reasonable to conceptualize certain disturbed Rorschach somatic imagery, as reflecting various forms of mental suffering, including unreported suicidal/homicidal fantasies (Cassell, 1977, 1979).

This conceptual model played an important role in the subsequent design of SIS stimuli. For SIS –I, the embedded inkblot material in Card XVIII and XX incorporate structure capable of stimulating the projective release of violent imagery from the viewer’s brain memory systems. For SIS II the same principle provided the impetus for designing images B15, B21 and B22. Work to date has demonstrated how this added structure has increased the projective pulling power of the SIS. However they have added a higher degree of occupational hazard by exposing the examiner to a higher degree of secondary empathetic trauma.

The four case histories in the present study serve to illustrate how the SIS can provide important information regarding violent fantasies (Cassell and Dubey, 1998, Cassell, et al, 2002). The direct and symbolic imagery projected can provide new insights enriching those obtained with standard clinical interviews. Members of this society are challenged to pursue this promising line of scientific investigation. We also must learn how to more effectively incorporate its spiritual applications into clinical practice Cassell et al, 1997, 2001). Perhaps we may improve in therapeutically communicating with suffering individuals such as JF:

“I have an obsession with death…death is very intriguing…its one of the only great mysteries of man that has never been solved…and it’s just my mind travels on a parallel…well it really doesn’t travel on a parallel…but it’s like my mind wants to question death…it’s like…it’s almost like it wants to experience it but yet doesn’t!” Clearly his “obsession” goes far beyond reality based cognitive psychotherapy and atheistic scientific interpretation. It demands a religious response consistent with his native culture and SIS body-mind-spirit theory. This could provide the support of an empathetic bridge reaching beyond biological death into the realm of eternal spirituality.

Stimulus Plate SIT-28: Combat PTSD / Intrusive Threat Matrix

The SIS-II Video/DVD version may be used as a hypnotic based memory stimulating interview aide for treating Posttraumatic Stress Disorder (PTSD). This psychotherapeutic application differs from standardized psychodiagnostic testing, where traditionally the interviewer primarily acts like a “blank screen” when enquiring about the psychometric properties of elicited responses introduced during inkblot viewing. In the much more active SIS approach, for aiding memory recall during the detailed enquiry, the psychotherapist may introduce outside relative clinical subjects from historical sources beyond the inkblots themselves.

The result is an optimum therapeutic fusion of input from the pulling power of projective technique and that of clinical interviews. This multidimensional technique will be illustrated in reviewing a transcribed television teaching recording using the SIS-II Video. The case involves an American Vietnam veteran suffering from long standing PTSD. Like many such military veterans, he had never sought treatment for his own mental symptoms. He had initiated treatment only after recommendation of his stepson’s family therapist. The youth had been deeply depressed and made a serious suicide attempt mimicking his biological father, who suffered from untreated combat PTSD and ultimately committed suicide. The stepson had never been able to bond emotionally to his PTSD disturbed stepfather, who had superimposed onto him, a guilt ridden mental picture of a boy he had blown apart in combat. The televised educational program illustrates how the cited SIS electronic technology hypnotically accesses vivid stressful memories of military combat for cognitive psychotherapeutic correction and affect reprocessing.

J: Okay.

Dr. B: At this point we'll look at image A1.

J: It looks like an x-ray of someone's insides.

Dr. B: Any special emotions or anything it brings to mind? ((The interviewer attempts to elicit the cognitive symbolic content and affect linkage of the anatomical response. This hidden material surfaces in projective awareness later in the interview with A10).

J: No, not really. (Here the symbolic significance and affect linkage is either simply denied or repressed. Consequently the interviewer elected to actively bring into the SIS detailed enquiry additional clinical information).

J: Yes, sir, I did.

Dr. B: How'd you feel about that? (SIS psychotherapy for PTSD actively brings into immediate focus, in the relative emotional safety of the clinician’s office, years away from the stressful combat scene. Therapy cannot effectively proceed without the victim experiencing a therapeutically controlled degree of emotional discomfort. This dysphoria concurrently becomes partially transferred to the interviewer, who must then empathetically internalize a portion of the suffering. When the responder perceives this transfer, by recognizing the SIS therapist’s verbal and non verbal clues, the stage is set for optimum cognitive and emotional resolution. The conditioning process is also facilitated by the viewing of healing flowers and nature scenes).

Dr. B: Did you have any of that sick feeling looking at image A1? (The SIS interviewer asks a “leading question” in order to bring into focus the affect linkage of his anatomical response, “Someone’s insides”.

J: It looks like somebody trying to hold on to something.

J: It's.....

J: It looked like maybe a child trying to hold on to something.

J: A lot of different color… Nothing in particular.

J: Oh, maybe a child in the womb.

J: It looks like possibly the face of a person, abstract.

J: No, not really.

J: Yeah.

J. Yeah. You can't... miss him in a crowd, that's for sure.

J: The teddy bear on the corner, security. A friend. The abstract on the side, I'm ‑‑ I'm not too sure.

J: Yes, it was. I'm just glad that there were people like yourself and Dr. F. (Family psychotherapist) that were there to piece him back together. That looks like somebody. It's abstract of somebody dancing or.....

J: Female.

Dr. B: Yeah. (The interviewer empathetically recognizes the intense level of the more immediate stress involving his stepson.)

J: Not only as his stepfather but as ‑‑ as a friend of ‑‑ of T. (Here he first reveals his confused perception of a dual role - that of stepfather and as well friend of his stepson) it ‑‑ you know, it ‑‑ you really don't know when something like that happens where to turn or what to do. You want to ‑‑ your ‑‑ your natural instinct is to ‑‑ to grab hold of the child and tell him everything's okay.

J: Well, that's abstract of I'd say a male, the hair and mouth. They're abstract arms and legs.

J: Yes, it was. It was.....

Dr. B: For him to accept it I mean.....

J: Him ‑‑ for him to accept it. He wanted ...he wanted us there, he wanted me there, but yet I felt as ‑‑ as his problem was completely out of my league.

Dr. B: That's right.

J: I knew he had a problem and I knew it was a real pressing problem for him to do something of this nature to try to ‑‑ you know, to take his own life. I mean I've been in tight situations myself, but I don't think I've ever got to the point where I wanted to take my own life.(Here he denies ever having experienced suicidal impulses which later are recalled).

Dr. B: Yes.

J: I mean life is hard, but I ‑‑ I mean I've had my own share of hard knocks, but kids today have more peer pressure. They wanted to be accepted more, I think.

J: It looks like oriental writing.

Dr. B: A10?

J: That looks like somebody's face that parts of it aren't there.

J: It looks like pieces of it have been blown away or removed. (Here long standing PTSD memories are pulled into immediate dysphoric projective SIS consciousness by A10).

J: Yeah.

Dr. B: Tell us about it.

J: I would see bodies floating down a river bloated, disfigured. You come up alongside of it to see if it had dog tags. If it didn't have dog tags you shot it and let it sink. If it had dog tags you retrieved the body.

J: Distorted, bloated, some of them were there; some of them weren't... pieces of their bodies missing.

Dr. B: Did you ever get images like that in your dreams? (The interview quickly moved from the real world combat scenes to that of sleep disrupting PTSD dreams still tormenting the veteran).

J: Yeah, the rivers ‑‑ the bodies floating in the rivers I did.

J: It ‑‑ it wasn't so much the ‑‑ the body in the river. It was the smell.

Dr. B: What was the smell like? (It is very important therapeutically to include a discussion of olfactory sensations, which frequently link emotions to PTSD imagery and dysphoric affect.)

J: Well, the first couple of times it happened I went to the other side of the vessel and put my stomach in the river.

J: Yes, sir. But then after awhile it ‑‑ it I guess it calloused a person.

J: You got numb to the fact.

Dr. B: Yeah.

J: And that happened about 90 days after you were there.

J: You just went numb. The only thing you were worried about was your own survival...

Dr. B: Did you ever get over that numbness? (The psychological defenses blocking out the stressful memories through processes of neural inhibition, also inhibited the psychobiological processes underlying the PTSD imagery affect linkage).

J: No.

J: I find myself ‑‑ I find it's hard for me to get close to people. Relationships. I've had three different ‑‑ three different relationships ‑‑ or two different relationships that have gone completely to pieces. And I feel that a lot of that was of my close off or my numbness effect or the...(It is common for such veterans to have problems with marriage. Not only did his untreated PTSD numbing block emotional intimacy with women, it also impaired his capacity for a close relationship with his stepson).

Dr. B: One of the problems we have in life J. when we turn off, as you have to do (in combat) are feelings and seeing something horrible then we turn off other feelings, love and intimacy and so we have some more work to do in your therapy. (The interviewer explains the nature of his symptom and emphasizes the positive value of treatment. It may be recalled, that in spite of the severity of his PTSD, that he had sought therapy only because of his stepson’s needs.) How about image A11?

J: It's a good abstract drawing of something, but I'm not exactly sure what. A nostril, maybe.

Dr. B: The smell is pretty strong at times? (The interviewer points out the association between his SIS heightened nasal awareness and the olfactory sensations in his PTSD dreams.

J: The stra ... yes, the smell of death and ... and decay. The people in Vietnam were not exactly what the American people would classify as clean. They were no by no means dirty, but their facilities, their living conditions weren't what we know of them in the United States. Just the ... I don't know, the sewage systems, their ‑‑ their way of throwing things away or their ... their ... their garbage or their waste, it's just wherever it happened to fall. And, of course, in a hot, humid climate that all.....

Dr. B: Be with you 24 hours a day.....

J: Was with you 24 hours a day basically.

J: I didn't see anything there.

Dr. B: Do smells still get to you? (Even 25 plus years later).

J: Some, yes.

Dr. B: Tell us about that.

J: Smells. Rotten eggs will usually do it, they will trigger old smells or old senses.

J: The streets. They had a delicacy that they called Nukbaum that was basically a fertilized egg and they would bury it and that was one of the smells that … that kind of stuck with me and it … it seemed to be in the areas of the cities or the towns. I don't know if it was so much that or if it was everything else combined, but it was not a very pleasant smell.

J: It looks like a hand reaching up or out of something.

J: It reminds me of one of the hands that I had grabbed hold of when I was pulling bodies up out of the river.

Dr. B: Tell us about it.

J: I was on the same patrols. You had to verify the ‑‑ the body that you seen floating in the river. You had to make sure it was an American or it was V.C. Viet Cong. When a body is ‑‑ when rigor mortis sets in you roll the body over and the hands and everything are stiff. And that image does...

Dr. B: It was ghastly at times, wasn't it? (The interview empathizes with his obvious dysphoria).

J: Yes, sir, it was.

J: Not good. I don't know what the feeling… if you can put a name to it.

Dr. B: Sometimes there aren't words for those feelings, believe me! (The interview comments on the lack of descriptive language to describe such emotional discomfort). Did you have anyone to share, you know, at the end of a tough day of dealing with a body like that or bodies in the river, I mean, did you...

J: There were no medical people or anything like that. The only. .. you know, you didn't talk too much about it between the other groups or people or the ... your other men on the boat because they're basically in the same boat that you were. They wanted to forget about it, too.

or...(Previously he had indicated that he had used chemical substances extensively out of desperation to induce sleep.)

J: Drugs or alcohol.

Dr. B: And what would you fantasize? To get away from there you'd think what sort of fantasies would...

J: I would think of home.

J: Yeah.

Dr. B: How about A14? I'm getting sick just listening, I'll tell you, this is … this is upsetting! (As was evident from his appearance and nonverbal presentation, the activation of his nauseating memories was causing him distress. Reflecting the interviewer’s empathetic feelings during the interview was supportive to him).

J: That looks like a stomach.

J: Not good!

Dr. B: Tell us about it.

Dr. B: What images of that come back as you look at that?

J: The kid laying there in two pieces.

Dr. B: His guts were exposed?

J: Yes, sir.

Dr. B: Tell us about it.

J: It's ... it's not a pretty sight. It's just...

Dr. B: Blood was all over?

J: Yeah. He came around the corner with an AK‑47 in his hands and I had no other… I had no choice. And I didn't realize it was a child until after I'd shot. (In this instantaneous life threatening stress, there was not enough time for his brain to cognitively process the reality based visual sensory input. His perceptual defenses immediately and out of his volitional control superimposed an image of an adult pointing a lethal AK-47 at him. His military conditioned central nervous system responded in a reflex like fashion sending rapid fire neural impulses to his trigger finger. Yet, he since had been plagued with guilt. He mistakenly believed that his action was preventable).

Dr. B: When you realized that what did you feel?

J: I guess maybe I felt like committing suicide at that time. Maybe … maybe I was wrong in saying I've never felt like committing suicide or killing myself ‘cause I didn't … I didn't feel good about it. (Here he recalls previous suicidal ideation that previously he had denied. It might be noted that he was a close military friend of his stepson’s father. After his buddy committed suicide, he married his widow. He was partially linked by similar PTSD imagery including the infectious suicidal ideation).

Dr. B: What did his face look like? What did his face look like?

Dr. B: It's hard to remember. But the guts and... J., what are you feeling now? 'Cause I can tell you're on the edge of tears. (Identifying and accepting as a healthy normal grief concomitant of the SIS triggered traumatic memory). Can you share that, please, do you agree?

Dr. B: There's still a lot of pain inside, isn't there? What's it like?

J: I wish that I could go back and change it.

Dr. B: You're feeling sad?

J: Guilty.

Dr. B: And guilty. What's the guilt like?

J: Taking a child's life. There's...

Dr. B: It's hard to live with, isn't it?

J: There's no reason for it.

Dr. B: It was a reflex and you didn't have a decision, it just happened, but over the years what ways has this guilt come back on you like now?

Dr. B: Yes.

J: I don't. I don't want to ever have any of my children either foster or adopted or my own to ever have to go through this. I've told myself, I've told Betty (his wife) that if the military was to go back to a draft they would not have any of my children. I'd say just take me.

Dr. B: You'd go and suffer again to save them from the pain. That's how loving you are. It's important that you forgive yourself. It's a crazy world. How did you feel about the Vietnam conflict and then as the change in its complexion and all and hear what was happening, are you getting any of the news or...

J: The news ... the news we were getting in country was ‑‑ was not anything like from what I understand and what I've been told by my father that, you know, at 6:00 o'clock, you know, they sat down and ate dinner to war‑ ‑‑ (Indiscernible) war. And the war that I was part of.

Dr. B: It's really outrageous, isn't it?

J: And the lying on our government's part, (Here in the educational interview, he began to experience his anger to the government political/economic figures as well as sense of betrayal related to the cognitive dissonance from initially perceiving himself as a patriotic soldier to that of a “Baby killer”). you know, after I got back I didn't realize that what kind of non‑support that the American people were giving to the Vietnam conflict. When I first came back I had a friend of mine, her name was K. L., picked me up at the airport. She worked at Berkeley College. And she picked me up on her lunch hour so I had to go back to Berkeley College and sit and wait in her car until she got off work. Well, as I was waiting there, students on the campus spotted me in my camouflage greens as I was stretching out getting some leg exercise and just kind of stretching and whatnot on the side of her car, that they called me everything from baby killer to, you name it, they called it. (The verbal abuse by the students using the label of “baby killer” added to his intense guilt). They damn near tipped her car over in the process of trying to get to me.

Dr. B: You're a brave man. You just (Attempting to support and restore his self esteem enjoyed prior to Vietnam.) (Indiscernible ‑ simultaneous speech)...

J: No, I . I jumped in the car and I was looking for a weapon, you know...

Dr. B: Oh, yeah, (indiscernible, simultaneous speech) feel?

J: Threatened.

Dr. B: You deserved better. You didn't deserve that. You had enough guilt on your own without having that dumped on you.

J: This is true, but I didn't ‑‑ at the time didn't realize what was going on the American side of it.

Dr. B: Yeah.

J: A lot of the people didn't want anything to do with the vets. They just ‑‑ they kind of closed the door. It's...

Dr. B: They took a holier than thou attitude. They weren't there!

J: Yeah.

Dr. B: Let's go on to the next image, A15. I appreciate your sharing J. What do you see here?

J: I ‑‑ remind me of a river entrance on a map.

Dr. B: Tell me more about it. A river entrance on a map?

J: Uh‑hum. We lost two boats going up. I say a display of a river, but it ‑‑ the river mouth was wide and it narrowed down into nothing. And once you get a 50 foot boat up a river to where you can touch both banks and then you've got somebody behind you and they open fire and you've got yourself a...

Dr. B: You're trapped?

J: You're trapped. You can't back up 'cause the boat behind is...

Dr. B: Yeah.

J: Getting the holy hell stomped out of them so the only thing you can do is ... is call in air and hope everybody comes out all right. (Indiscernible ‑ simultaneous speech)...

Dr. B: Do you remember that situation?

Dr. B: Tell us about it.

J: We ran up a … we were on normal patrol and we were supposed to ... it was on night patrol and we were supposed to set up ambushes. And we saw this entrance and it was a pre given location where we were, all gone over prior to going out on patrol, that we would set up ambush on the r.. on the mouth of this river, but we had to go back up in it, but nobody else had gone in there during the day to find out exactly how much room a person would have, because Charlie (nickname for Vietcong) was kind of funny. He liked to work at night and did most of his ambushing and whatnot at night. His staff, it was moving medical supplies, ammunitions along the Ho Chi Minh Trail was done at night. You get yourself into a situation you pulled up that river. And we pulled up and the boat behind me pulled in. They took a B‑40 heat round in the fuel tanks and we lost that entire boat. And then we ended up in the process of the fire fight we called in air strikes, called in six Cobras and they came in and just basically cleaned house. We got the men back out. It was, all of them that weren't there no more. And the funny thing about it is I can't remember their names or their faces. I don't know if I've mentally blocked it or what.

Dr. B: You've mentally blocked it, but it's so close to consciousness when you're looking at these images it's very real, and I suspect that you've had that in your dreams too, more than once. Next image, please, A16? What does this bring to mind J?

J: I didn't see much there.

Dr. B: What do you see there or did you? It’s okay. We'll go to the next image, A17. (The SIS-Video was running at its normal rate because of the educational nature of the televised educational program. Otherwise in traditional detailed SIS enquiry, more time may be taken to explore memory associations triggered by the visual series).

J: It looks like a chest cavity.

Dr. B: And how do you feel looking at that?

J: Basically the same. It's just a sick feeling.

Dr. B: And what's it remind you of?

J: Just death and destruction itself.

Dr. B: You saw too much of that. A18?

J: That looks like a heart of something and the drawing of a heart with something in the middle of it.

Dr. B: Any feelings or thoughts about that?

J: No.

Dr. B: Okay. How about A19?

J: That looks like an intestinal tract. Your lower intestines.

Dr. B: Anything more you want to say about that?

J: Then it's right back to my ... the kid.

Dr. B: Back to the kid. His intestines. Like to say a little more about that? Your feelings are very close to the surface with that, aren't they? Where did you ‑‑ where did the blast catch him?

J: Mid‑section. Double Ought to Buck. (Lethal shot gun lead) It was the only thing we could.

Dr. B: Yeah. A20?

J: That looks like an abstract of Mickey Mouse, but...

Dr. B: Anything else?

J: No.

Dr. B: I wish we were in a world where we had like Walt Disney, fun times and characters and less trauma for kids. A21?

J: Looks like an animal that may have been dressed … dressed out or a bird or...

J: I used to, but I don't anymore.

J: That I ... I can't answer that. I don't know if it's ... if it's related with … with ... with my experience in Vietnam, but I just used to be an avid hunter and fisherman. I...

Dr. B: Yes.

J: Don't do much of any of it.

J: It looks like a drawing of something with a kind of like a headdress on it or something to this effect.

J: It looks like the spinal cord.

Dr. B: Any feelings with that one or...

J: I come out of it without a scratch.

J: Oh, yeah. I had two boats blown out from under me in the process.

J: Two boats blown out from under me.

J: I counted my lucky stars. I was stuck on the … on the beach for six days.

Dr. B: The guy upstairs wanted you to get through. (The interviewer spoke using spiritual symbols that this veteran had previously reported to the family psychotherapist).

J: He had something else in store for me that am for sure.

J: Possible abstract of the lower extremities of a female.

J: Not particularly.

J: That looks like a wound.

J: A wound.

J: I don't know about how I feel, but all wounds come in different sizes and shapes. It looked like a knife wound.

J: I don't know if I can remember any particular incidents. Just the way the ink blot formed it looks like maybe somebody opened a wound up to irrigate.

J: Oh, yeah.

J: The enemy was the enemy. I mean they were it was … they would ‑‑ before you went over there your ‑ your mode of survival was anger. They pumped you up. Like when you went through survival school they pumped you up the whole time. The only way you're going to stay alive is stay mad.

J: It was just a drone more than anything. When you were on patrol you were alert. As soon as you received fire from the beach it was like triggering a mechanism within inside. It was instant anger.

J: It was joy. You've taken ‑‑ you've taken the enemy out. And usually they don't wound them. It was you killed them, period.

J: Sick, but yet I felt and was trained that it was something that had to be done. It was either him or yourself.

Dr. B: That's right. Conflict is conflict. So you saw a lot of wounds just...

J: Yeah.

J: That is definitely a fetus in the uterus.

J: Good.

Dr. B: It's good there's hope and life, hopefully in the future children will have a better chance.

J: (Inaudible).

Dr. B: In a regressive mode back in your childhood, happy years or whatever.

J: Yeah, there ‑‑ there were times that ‑‑ that I wished that I could stop the clock and turn the hands back, yeah, and start again.

Dr. B: A 27?

J: It looks like a breast.

J: Tender.

J: Women yes, whore no.

J: They were ‑‑ they were, you know, female companionship, but it was ‑‑ the emotion wasn't there. They were there for one thing, that was the money. There was...

Dr. B: There wasn't love of war for.

J: No. It was...

J: Yes.

J: Oh, yeah.

J: Well, you get to thinking of home. I'd get to thinking about where I would be if ‑‑ if my life would have been different, if my mother hadn't passed away, your mind does ‑‑ you know, your mind wanders.

Discussion:

This educational video illustrates the use of the SIS II Video as a psychotherapeutic aide in treating military combat induced PTSD. The SIS projective procedure serves as a modern day “Time machine” accessing traumatic memories laid down years earlier. Past stressful scenes were brought to mind for cognitive correcting and emotional reprocessing in the relative safety of the professional setting. Subsequently the veteran’s individual psychotherapist then had the opportunity to undermine erroneous cognitions sustained originally, when the victim’s judgment was distorted by stress related combat emotions. This therapeutic process can be amplified by follow-up group psychotherapy discussions. Empathetic veterans can emotionally support their buddies when sharing their corrective insights.

The educational video also illustrated the infectious nature of stressful PTSD death imagery, especially with regard to suicidal ideation. Death seeking escapist impulses infected the minds of the veteran under review, his stepson, who made a serious suicide attempt, and the boy’s biological father, who after suffering from untreated PTSD, ultimately did suicide. Not shown in the teaching tape was the extensive follow-up therapeutic work involving family psychotherapy, including this veteran’s wife. After her first husband killed himself, his military Vietnam veteran buddy eventually married her. Thus, although she never had been in combat, the Vietnam War had caused her great grief.

Many such veterans and their families are still suffering from the long term psychological injuries of warfare. The majority are untreated. Most are reluctant to seek help from limited treatment resources. There are realistic restrictions concerning the cost/effectiveness of such intensive care that necessarily requires many providers involving multidisciplinary therapeutic strategies.

Since the Vietnam conflict, much has been learned about the nature of PTSD from the military’s traumatic experiences in Iraq and now Afghanistan. Although some recruits may be particularly susceptible, in general, the mental health of troops fluctuates with the severity and duration of exposure. For example, as the stressors in Iraq have recently fallen, the suicide rate has leveled off. Consistent with senior members of the military increased awareness, troops are being given more preventative information regarding self destructive impulses. Also helpful has been the availability of playing video games or access to the internet, providing that these outlets did not exceed four hours daily. Moreover, troops who exercise or do other forms of physical activity have a greater resistance to stress.

Apart from prevention of war, which appears almost irrationally utopian, in view of our historically violent world, new technological based programs warrant consideration. Consistent with this, one of the above authors (Wilfred A. Cassell) has recently developed a SIS based computer controlled visual combat series to stimulate the release of military PTSD imagery. It includes all the self administered and hypnotic features of the original SIS II Video. Through computer controls the mental health therapist has the power to focus more on visual scenes themes involving military stress that are specific to the soldier.

It capitalizes on a previously behavioral conditioning therapeutic principle that was unmentioned in the above case presentation. This involves the technical fact, that after each SIS presentation, the viewer instantaneously witnesses for a few seconds a beautiful flower and afterwards beautiful nature scenes accompanied by relaxing music. Such potentially anxiety reducing healing sensory input are then superimposed on the fading “after image” of the just released PTSD imagery. Theoretically, this sets up in the brain’s memory storage neurons, physiological situation where stress related neurochemical previously released at the nerve endings may be neutralized by those enzymes released by the calming nature scenes.

Since many PTSD victims develop secondary addictive problems from self-medicating, the visual series begins with alcohol and drug related scenes. Next in the monitor, SIS “inkblots” suggestive of stressful combat scenes are viewed. After the viewing procedure, the subject selects the most “Disliked” or threatening scene. Then easily controlled computer programs enable the therapist to repeat the presentation. This follow-up viewing stage presents the most anxiety provoking stimulus in a repetitive fashion, followed in a brain conditioning sequence by the calming floral presentations and relaxing nature scenes. This method of therapy produces material for traditional therapeutic approaches, such as cognitive psychotherapy and therapeutic analysis of recurrent traumatic dreams. In addition, it supplements these with concepts derived from behavioral therapy and conditioning. Since it uses much less professional time, it is more cost effective than older traditional methods.

Readers interested in conducting clinical trials of this computer based SIS system are invited to contact the authors to obtain CD discs. They are also encouraged to insert “Virtual PTSD Treatment” into an internet search engine to learn about similar innovative research strategies. However, all need to be forewarned about the additional occupational hazards of being exposed to secondary or empathetic PTSD imagery.

Activating stressful memories of combat with new technology can be hazardous. Surely the intellectual reader who has empathetically followed the above case presentation must now have potentially disturbing visual images recorded in his/her visual cortex. Subjectively identifying with the veteran and imagining the grotesque imagery involving a Vietnam child’s body being blown apart and its long term psychosocial consequences places the sensitive soul at risk.

Not only are professional more aware of this hazard, some of the American public are as well. Relevant to this is an Nov. 8 front page article in the New York Times entitled “Who’ll counsel the counselors? Military Faces Therapy Overload”: “many of the patients who fill the day are bereft, angry, broken. Their stories are gruesome, their distress lasting and the process of recovery exhausting. In time the repeated stories of battle and loss can leave even the most professional therapists numb or angry.” Be forewarned that those who use the SIS and virtual reality technology are more at risk!

The case study reveals therapeutic fusion of input from the pulling power of somatic inkblot images (SIS-II Video) and clinical interviews. The case involves an American Vietnam veteran suffering from long standing PTSD. Like many such military veterans, he had never sought treatment for his own mental symptoms. He had initiated treatment only after recommendation of his step son’s psychotherapist. The youth had been deeply depressed and made a serious suicide attempt. The televised educational program illustrates how the SIS electronic technology hypnotically accesses vivid stressful memories of military combat for cognitive correction and emotional reprocessing.

Their symbolic imagery revealed in a disguised form her family stressors and her “inner cry”. Even though she was an adult, her mother in law’s criticisms greatly undermined her sense of confidence. It is understandable that her extreme vulnerability led her to somatize her feelings and imagine “fainting”. Yet her initial response to early psychotherapy had begun to restore herself image as being a competent mother to care for her child. The rich and graphic SIS symbols now need to be effectively translated into the language of psychotherapy making up for the paucity of words to describe emotions.

This case illustration involves a 28 year Engineering graduate severely depressed woman with multiple somatic symptoms. These included a sensation of heaviness in her head, various discomforts throughout her body and a year’s duration of “falling unconscious”. Psychosocial history revealed a number of significant stressors. The onset of her complaints occurred after her marriage two years previously when she moved into her in-laws home. She complained that her mother in law was too controlling: “Nobody can do anything without her permission”. She used to shout at me for small things; she says that I am nothing except my education. She is very dominating and expects that everybody do, the way she wants”.

Gradually she started avoiding her abusive mother in law, yet she could not avoid her completely. After episodes of verbal abuse, she began to subsequently imagine persistently hearing her critical voice and persistently feeling anxious retreating to her room. Gradually she developed more problems. She began experiencing fainting spells and claimed that she was “unconscious for long periods”. Things even got worse after she gave birth to a child, when her mother in law took over total care of her infant. After the first year she was allowed to assume some responsibility for the child. Yet her confidence for providing adequate care was very low, consequently her anxiety increased, as did her fainting.

The SIS-II Booklet was administered to uncover psychopathology and as a basis for developing a language for more effective psychotherapy. The significant responses are analyzed and discussed ahead:

A 1: 1.Looks like an elderly man without head. This response is a symbolic projection of her weakness and lack of social power in dealing with her mother in law’s domination).

A 2: 1.Puppy pushing a piggy.(Here the “puppy” symbolizes herself attempting to overcome and push out of the way her mother in law, in order to assume care of her own child).

2. Two person making whirlpool. (This symbolizes her struggle not to be pulled down in a fainting spell by her socially stronger mother in-law).

A 3: 1Looks like a shroud magician trying to do some magic. This may indicate that someone is trying to dominate her.

2. Lord Ganesha (This image of a God like elephant headed God having a large trunk and big mouth depicts in symbolic form her domineering verbally abusive mother in law).

3. Little birdie saying bye. (A symbolic portrayal of her losing attachment with her child).

A 5: 1.A bat flying---Vulture flying---.Heart carried by both of them. (This portrays the vulnerability that she feels. She has a feeling of love for her child in her own heart but senses his distancing).

A 6: 1.A sweet teddy bear (This reflects her positive feelings forward her child that she is so desperately trying to care for).

2. Ball hitting a wicket: Indicate aggressive contents.

2. Two snakes grabbing food: may indicate erotic conflict and aggression.

3. Man throwing a big stone. (This suggests her own feeling of being a victim. Quite possibly her husband supported his mother in her criticisms).

A 8: 1.Something hanging in space is leading to darkness. (Here the “darkness” symbolizes her depression).

2. One picture looking like a dragon. (This is a symbolic representation of her relationship with her dominating mother in law).

A 10: 1. A picture of a lady with burnished eye and crying. (This is a direct projection of her “inner cry”. This symbolism provides an important interview lead for her psychotherapist in assisting her to express dysphoria and grief).

2. Two frogs jumping (Normal response).

A 11: 1. A crow hanging downwards. (Like in 8a this indicates her sense of isolation and depression).

2. Liver (As part of her withdrawal from her stressful social environment, she has focused on her own body as a psychological object. Minor body sensations are now experienced as conversion pain and weakness).

3. Flying dragon. (This represents a symbol of her mother in law).

A 12: 1. A human ear (Normal response).

2. Small baby (Her longing for her child is reflected in this response).

3. Jesus Christ. (Her extreme sense of suffering and betrayal may be causing her to identify with religious symbolism of being abandoned and crucified. Alternatively this can reflect her reaching out to God for help).

A 13: 1. A hand being surrounded by small insects. (This symbolizes the ever present stinging criticisms that she is bombarded with daily).

2. Human brain. No doubt her social stresses are flooding her mind, making her more conscious of her thinking. This plus her headaches are determining this anatomical response.)

A 14: 1. A human spinal cord attached to stomach (Normal response).

2. Water spilled in a pit out of a pipe. (This depicts her perception that everything has gone out of her control).

A 15: A baby hanging and being engulfed in darkness. ((Her stress has caused her to mentally regress, feel helpless and at times faint. She is engulfed in a psychological sea of dark depressive emotions. Not only does she need psychotropic medication, she requires psychotherapy, both individual and family involvement is indicated).

A 16: 1.Two birds playing. (In spite of her hopelessness, she still clings to the notion that everything will work out in the future in her marriage).

2. Plant growing. (She has benefited from her initial psychotherapy and sense personal growth occurring).

A 17: 1. Human ribs and human lungs (Normal response).

2. Two seahorse eating food (Normal response).

A 18: 1.A wolf being surrounded by two big dragons. (This response symbolizes her family situation involving the mother in law and one other controlling person. The family psychotherapist needs to ascertain the identity of the other “dragon”. Perhaps her critics have depicted her wicked wolf eating their resources).

A 19: My head is aching while watching this picture.(While the symbolism described above has served to defend her from facing directly her family stressors, eventually the release of the stressful underlying imagery triggered one of her main somatic symptoms).

A 20: Human kidney and urinary bladder (Normal response).

A 21: A starfish --Small baby and other baby crawling. (Caring for her child is on her mind).

A 22: 1. A monster with heads joined and a horn coming out of it with claws. (This again symbolizes her threatening family situation).

2. Two baby elephants.(Again the heightened awareness of “Baby” imagery.)

2. Small birdies sitting one over the other on a pot being balanced on a stick. (Her interest in her child causes her in this response to see “small birdies”).

2. A monster with fire in his hand towards left. (Another response like in A 22).

3. A big lizard (Like A23)

A 25: 1. Like a candles flame. This might indicate her repressed conflict in erotic area.

2. An owl looking scary. This indicates her feeling of insecurity and suspicion.

3. Lizards. Erotic connotation is projected through this response. The Therapist should explore this area during therapy.

A 26: 1. A baby (Normal response).

2. An elephant resting (Normal response).

A 27: 1. A cave. This might indicate her conflict in erotic area.

2. Volcano bursting (She feels like bursting from the tremendous flood her “inner cry” attempting to surface.)

3. A cat holding something long like snake in to mouth (Disguised sexual feelings.)

A 28: 1. A muscular human hands (Normal response).

2. A wolf standing behind a tree. This again symbolizes her threatening family situation.)

A 29: 1. A deep groove beside a flat hilltop.

2. A crow in search of food. This indicates her insecurity.

A 30: A human skull (Normal response).

A 31: 1. A man and a woman (Normal response).

2. A boy with a cap running.

B 1: 1. A cloud of gas looking like an octopus.

2. A man falling with high speed.

B 3: 1. Two person watching horror movie in cinema hall.

2. A girl working on computer. (Normal response).

B 4: 1. Statue of a man (Normal response).

2. A dead female (Female Ghost/Witch) with bloody eye and mouth and no nose. (On the basis of this death symbolism, it is important for those clinicians providing care to check for unreported suicidal ideation).

B 5: A man and a women sitting on chairs in a tent with some hanging lamps.

B 6: Human legs (Normal response).

B 7: 1.A leaf being eaten by small insects. Indicates her helplessness.

2. A flower garland (Normal response).

B 9: Human kidney turned upside down with bladder upwards (Normal response).

B 10: A kid hiding from a dragon between two big wild leaves.

2. A hat (Normal response).

B 12: 1. A cruel magician with a big nose ring.

2. Dragon holding a kid’s head. (By now the reader can interpret this symbolic material consistent with the above formulation.)

B 13: 1. A giant robot. This may indicate authoritarian figure with aggressive contents.

2. Hawan kund (This may depict her own feeling of being burned or sacrificed by the family).

3. Lord Ganesha. This may indicate her spiritual strength while feeling helpless.

B 14: 1. A pot trying to fetch water (Normal response).

2. Beetle leaf (Normal response).

B 15: 1. Fire crackers. This may indicate her aggression and hostility.

2. Many grasshoppers and spade like knives attacking someone and the person trying to protect himself with his rod. (At this point in the protocol, hopefully the reader is learning to interpret the reoccurring symbols depicting her stressors.)

B 16: 1. A top (Normal response).

2. Small birdies sitting on a top (Normal response).

B 17: A burning heart and flames coming out of its. (The symbol of a “burning heart” may be translated by her psychotherapist during therapy to more effectively release her “inner cry”, than traditional language for suffering).

B 18: A big anaconda like snake in sea trying to pass through a groove. This may indicate her insecurity.

B 19: 1. A bug (Normal response).

2. Sun being broken in pieces. This indicates her depressive contents.

3. Insects trying to enter moon. The insect may connote her mother in-laws who is intruding in her life.

B 22: 1. A man sleeping and lost in his dreams. This may indicate her wishful thinking to have good time.

2. A man drowning in water but protected by a shield, (While prior to initiating treatment, she had a depressive sense of hopelessness. However, she now feels hope for the future, now protected by the “shield” of her psychotherapist.)

B 24: 1. Aladin’s lamps in water. This may indicate her wishful thinking that some spiritual power may help her in improving her present condition.

2. A saint standing on a flying carpet. This indicates her feeling to flee from the present environment.

B 25: 1. Future being seen in magic bowel (Feeling of insecurity and depressive contents).

2. Fire burning in a cave. This might indicate her repressed conflict in erotic area.

B 26: Leopard and a ghost. This may indicate her insecurity and fear of being tortured by her mother in-laws.

B 27: A newly born child and another Fetus. (Normal response).

B 29: A man running towards light. (In spite of all her stressors, at a deeper level of awareness now that she has initiated treatment, she has hope – symbolized by moving toward “light”.

B 30: 1. Right and left ear closed in a glass bowl (Normal response).

2. A man coming out of right ear. (While she has no overt psychotic clinical features, this response has a bizarre quality).

B 31: A happy family ma, pa, two kids. (This response, like B 29 again points to a positive prognosis).

It is evident that many of her SIS projective responses reflected the severe extent of her depression. Their symbolic imagery revealed in a disguised form her family stressors and her “inner cry”. Even though she was an adult, her mother in law’s criticisms greatly undermined her sense of confidence. It is understandable that her extreme vulnerability led her to somatize her feelings and imagine “fainting”. Yet her initial response to early psychotherapy had begun to restore herself image as being a competent mother to care for her child. The rich and graphic SIS symbols now need to be effectively translated into the language of psychotherapy making up for the paucity of words to describe emotions.

The following televised teaching interview illustrates the use of the SIS II- Video version in the psychotherapy of a man recovering from alcoholism.

Dr.: “M., I appreciate your willingness to be interviewed in this television studio. Thank you for your willingness and courage to share some of your emotional pain in this educational setting. Perhaps you could again express how the SIS images that you viewed recently in the television version of the SIS II aided you in expressing your feelings. Please tell us as well about your worthwhile work with AA.

Let’s begin with A30, the SIS image that bothered you the most.

M.: “I see death there…a lot of despair and pain…basically what I’m feeling now. (In responding to the SIS stimulus that bothered him the most, he spontaneously spoke about his severe depressive feelings and its cause).

M.: “I have abused alcohol and other drugs for 25 years…and it has finally caused my marriage to break up and I’ve lost my family…I am having a very hard time dealing with that…A30 just reminded me of all the pain and hurt that I have caused.

M.: “Emotionally…I wasn’t there for my family…I’ve wasted tons of money over the years on drugs and alcohol, that should have been spent on my family…I mentally and physically abused my wife for a number of years…and, basically, they couldn’t take it any more …and I’m not with them anymore.

Dr.: “Rage?”

In this regard, the SIS II Video/computer versions may be presented as a stimulus for AA meetings, as well as other forms of group psychotherapy.

SIS Assessment of Somatic Conversion Symptoms:

Earlier in this handbook a theoretical model outlined how psychological stress may become mentally converted into a variety of physical symptoms. This case history illustrates the use of the SIS II Video in a middle aged woman. She experienced an activation of her Dissociative Disorders conversion symptoms during the stress of conjoint marital psychotherapy.

She was referred for projective testing by her female psychotherapist for this televised teaching program. A transcript of the educational interview follows:

J.: There was no pain. It felt like, it felt like when a person almost passes out and it feels like they’re enough conscious to know what’s going on but they’re not able to do anything.

J: Yes.

J: I was sitting in a chair very similar to this and I started to get very dizzy and it got worse. It was more than dizziness. It was like my brain stopped processing. Like I couldn’t think. J. asked me to write down my feelings, she told me that she understood what was happening to me and if I wanted to remember anything about the session I needed to write it down because when I came out of it I wouldn’t remember anything. And I couldn’t write.

T: I was able to write one sentence and that was all I could do.

Dr.: Sort of almost a motor paralysis too? (The thought and PTSD memory blocking neural inhibition spread from the higher cognitive systems involving self and body awareness to the motor cortex inducing a type of catatonia. Initially the resultant reduction in somatic awareness led her to experience “Dizziness”. Subsequently this was followed by paralysis of her arm muscles used in writing. This sequence illustrates the close temporal connection between cerebral activation of psychological “Repression” and transmission of neural stimulation to external body skeletal muscle fibers. An observant interviewer can detect the onset of this defensive process by noticing changes the ongoing concomitant changes in body posture and movement. Techniques which reduce skeletal muscle tension, such as hypnotherapy and intravenous muscle relaxing drugs, can reverse the process.

The reader interested in this phenomenon and its effect on SIS evoked imagery is invited to review in the book Body symbolism, clinical cases outlined in the chapter on “Somatic Repression”. Moreover, in the chapter on Schizophrenic disorder, there is an example of reversing this sequence in an individual experiencing catatonic features)

J: Yeah.

Dr.: Yeah.

T: D., my husband, values me. That was the only thing I wrote.

S.: I was nauseated and I felt like I had a cold, hot and cold flash (stress induced cardiovascular sensations) but just the cold, you know. Almost like fear and when I got up to get out of the seat, that was when I realized there was really something was wrong. I could not walk. I literally did not have any balance at all. And I couldn’t communicate. I couldn’t think.

S.: About 7 hours.

Dr.: That was pretty scary. (Recognizing her anxiety in a supportive empathetic comment).

S.: Real scary. So D. had to drive me home and on the way home I realized I had had it happen to me before once but when I was at home and I was sitting at the kitchen table. I remembered that it had happened to me two or three times before. And then it got worse. (Her conversion symptoms had become activated by previous stressful marital situations). J. told me that trying to do normal activities and that would probably bring me back. And my son was being babysat so I didn’t have any distractions worrying about him. And I tried to wash the dishes and I couldn’t. I couldn’t, I couldn’t focus, and you know it was almost like a person feels when they’ve been kicked in the head. They, they’re just not able to do it, you know.

S.: In particular there were two things… D., my husband, was there this time and was in the therapy session with me so J. could educate him on what was happening to me.(Educating the spouse in regard to what was happening in regard to her symptoms as well as the positive prognosis with psychotherapy was important. This serves as a reinforcing force to support his long term commitment to the marriage).

Dr.: Yes, that was good.

S.: And to help me and him to really see what was going on because I have a hard time communicating it and that helped a lot. And in the process we were talking about the similarities in my behavior. How my behavior is a lot like my mother’s in a way that I’m demanding and intolerant at times. (Historical material linking her behavior with her mother’s past personality problems proved highly stressful. While children tend to acquire characteristics of their parents, it often is anxiety provoking in adult therapy to examine the similarities and differences.) Sometimes I say D., I need to do this. I don’t ask. I just shove it in front of him, you know. And I get mad if he doesn’t understand that’s what I want, you know. I don’t ask and I just shove it in front of him and I think that was where I started feeling bad and I’m starting to feel bad now. I’m starting to feel things shut down just thinking about that.(In this illustrative interview, in describing her irritable, maternal like marital behavior, she then began to experience similar Conversion symptoms).

S.: Well, when I first looked at it, it just looked like a clown to me and it felt safe and friendly.

S.: I see a very happy child, delighting in life, playing and just feeling free and at peace.

S.: It brings to mind for me a feeling of completeness.

S.: B17. It was a heart that just kept growing and getting bigger. That’s what I saw in it. And it was a type of color that was peaceful to me and I felt joy, compassion and love. That’s what it made me think of.

Dr.: Yes and that tells us that you have a capacity for joy, compassion and love and that’s going to grow as time goes on with your therapy. (Supportive comments to further reduce anxiety).

“Disliked” SIS Projected Imagery:

S.: Well, the reason that was upsetting is that I keep having that one in my dreams. (Recall the earlier discussion in this handbook concerning how the SIS electronic technology taps into the same stream of consciousness as PTSD dreams and anxiety charged memories).

S.: It represents to me – it looks like a fungus animal that could hurt me. And in my dreams I keep having this type of fungus that attaches itself to me, to my skin. (Here a defensive dream symbol emerges involving threatening body imagery. Although this has high anxiety linkage, it serves to defensively hide her deeper more heavily affect charged painful emotions… the source of her Conversion somatic symptoms).

Dr.: That must be horrible? (Empathetically recognizing her distressed emotions).

S.: And I’m pulling it off and getting rid of it and it’s very threatening but I’m getting rid of it in my dreams.

S.: I know they have something to do with the depth of pain, that the hurt that I have represents or it wouldn’t look like a fungus. It wouldn’t look so threatening to me. (Previously in psychotherapy she had begun to realize the therapeutic value of dream analysis).

Dr.: It’s very deep and very threatening.

S.: And it’s alive. That’s the other thing that makes it very threatening to me. It has a life of its own. And then I’m able to pull it off of me and get rid of it.

S.: That it will be OK.

Dr.: That you can work things through. (A positive statement to encourage facing the emotional discomfort of analytic psychotherapy).

S.: That I can work things through and that it will be painful too because it always leaves a sore.

Dr.: It’s very painful. Remember that I said that.

S.: I’ve had the dream about three times. (Recurrent dreams are important to analyze).

S.: This is a hand, to me, that is reaching out for help, that’s trapped. Somebody that’s in distress it symbolized to me my mother’s hand and I felt very helpless and I felt like the person, somebody that was suffering and I was helpless to help them. And that’s what it represented to me.

T: In the past I was the caretaker.

T: My mother was a drunk when I was a kid. And I was her caretaker basically. I don’t remember, I don’t remember hardly any of my childhood, it’s just, it’s just all blocked out. But I do remember always being the one to bring her this, to mop the floors, to clean the house, to bring her, her cigarettes and buy things for her at the store. I’d do those kinds of things for her and being real concerned for her. I specifically remember one time crying on the way to school because mom had told me that when I got back she would be dead because she was going to kill herself while I was at school.

Dr.: It was horrible.

S.: But I particularly remember going through that and I was wondering what was going to happen to me. That I didn’t want her to die.

Dr.: It was scary.

S.: The whole thing was threatening and scary to me. That was about 7 years old.

Dr.: 7 years.

S.: Grade school.

Dr.: Appreciate your sharing that.

And then B19 was the third one you rated as being threatening. What do you see there?

S.: Well, it definitely wasn’t a sun. It looked like an amoeba to me. It looked like more of the same. It looked like a living organism that was going to attack. And the two hearts to me, represented, on each side of it, one represented me, one represented my husband and this was a threat to us but it also looked like was, it also looked like in the picture that it was already beginning to well, it, the amoeba looking thing’s got cracks in it so it looks to me like somebody’s already hit it once or twice to get rid of it. But it represented a threat to me.

S.: The disharmony between us. The inability to really communicate and understand each other.

S.: The first one represents my home. It’s a drawing of a crooked house with a broken window with bars on the front door.

S.: For me it’s a visual drawing of the war that was going on in our family. I don’t really have any memories, per se, of the exact things. I know that looking at that I’m almost ready to cry.

S.: I feel a lot of anguish and pain.

T: It’s a drawing of a child, a little child, preschool with a spike and a nasty face in front of the spike, which doesn’t have really it’s just the eyes and the mouth and the mouth have teeth. It represented the heaviness, the weight, the weariness and the pain that the certain something that I was so afraid of that hurt me. I don’t know if it was, it was nameless that’s why it was a face. I couldn’t put a man or a woman’s face on it.

S.: Yeah.

S.: The way that I feel emotionally and psychologically and the weight that I was physically feeling.

Dr.: How about the next one there, S.? The third one, I guess.

S.: It’s a picture of the same child, in a box with a maze around it. Then and there’s no way out. The box is closed off. Although the maze has an entrance the box doesn’t have an exit. With a pair of scissors and it’s in black and white. These are in black and white, the first drawing and the third one, because my world was black and white. There was no love, there was no color. There was no life. The scissors are cutting through the maze. They have wings on them because they are from God. I feel like that God himself is healing me through therapy and what other ways He’s choosing to do it.

Dr.: Anyway, you’re feeling God’s healing with this pain. (Supportively speaking her spiritual language). Let’s do the next drawing. Let’s see.

S.: One, two, three, four. Four is a little child in a tunnel. It was what I was feeling when I was out of it, unable to concentrate and unable to really move around. I felt like I was in a tunnel.

S.: I would feel like I regressed all the way back to infancy, if that’s possible. Not quite infancy but toddler hood.

Dr.: It’s possible.

T: Preschool. I felt like on my way out that I was that I needed to be carried, literally carried like a little child. That I’d been severely hurt.

Dr.: Yeah. You needed comfort and love.

S: Yeah. I felt, I felt that I got in touch with those real tender, tender feelings.

Dr.: Um huh. That was good.

S: That I don’t think I felt before.

Dr.: It was good that D. was with you.

S: For a long, long time. (In the above comments, she documented the significant age regression that is associated with the expression of severe psychological stress in psychotherapy. Like the above outlined “Repression” mental /neural mechanisms, this too is associated with clinical changes. Dramatic examples involve remarkable alterations in the human voice: A subject may speak with a voice replicating their childhood immature one or in severe Dissociative Disorder speak with the voice of an alter identity representing a perpetrator of the opposite sex etc).

S.: The next drawing I tried to put a face on what it was that I was so afraid of. What it was that, the nameless thing that put me in a state of semi-shock? And I know there was sexual abuse in my family. I’m making an X with my hands because I crossed out the face after I did it. It didn’t feel right. It didn’t feel like that that was the right representation. I couldn’t, I couldn’t figure out what it was. And I started with a man’s face because I know there was sexual abuse in my original family. I was adopted. My very original, natural family I have no history. I was adopted when I was four days old so the sexual abuse happened in my adopted family.

S.: The perpetrator was my step father and involved my cousins. It supposedly did not involve me. My mother says but I’m not so certain about that and anyway when I drew the man’s face there it didn’t feel right so I crossed it out. And number six is a picture of representation of my mother. She has on a red dress because she is angry. Her nose is red because she’s drunk. She has a beer in her hand and there are swirls around her head because she’s not, she’s not sober. She’s incoherent like she was most of the time. That felt right. I knew that had really happened in my life. When I drew that it felt like truth to me.

Dr.: Yes.

S: And, the next one, the next two were all faces. I was trying to draw myself again, to focus on who this little child was, what it was, who I was, what age I was, this trauma was going on at that I was in touch with and they weren’t right so I crossed those out and when I got to this one, I feel like that this one was right.

S: This next one is just a little child, scared, alone and hurt and I’m drawing her inside of a tunnel because I felt like I was in a void. I felt like I’d been sucked into a vacuum.

Dr.: That’s very scary.

S: Yes, it was very scary. And, it was very, very painful. And I felt like there was a lot, a lot of grief, I was feeling a lot of grief, a lot of pain and it was just plain shock like something and I kept saying over and over again to myself, “something happened to me and but that was it?” And I couldn’t remember but I had this sense that something happened to me and I didn’t know what it was.

S.: Um huh.

Dr.: Let’s have you look at them in order. A1. Can you tell us what you saw and what that brings to mind? We have a number to do so we are going to move a little more quickly this time.

S.: A1. Two seahorse heads. First it reminded me of blood because the video image had red in it.

S.: Violence. Knives.

S.: A lady dancing in the mud and getting hurt.

S.: It brought to mind fear, like there was danger.

Dr.: You feel in the mud at times, I imagine.

S: Um huh, or I’ve been in the mud.

S.: That was the one that looked like the fungus that we spoke of.

S.: A broken toy and I was upset by that.

Dr: Tell us about that.

S.: I really felt that broken toy really strongly, like something really precious to me that somebody had deliberately broken it out of spite and I was upset.

S.: Yes. I don’t recall that childhood experience but that’s what it.

Dr.: And A5?

S.: A5 was the clown that made me happy and felt safe.

S.: 6A was the child. A child who has a teddy bear next to it that looks like he’s been scared to me. Something had happened and scared him and he stopped playing and he’s frightened.

S: Just feelings, no memories.

S.: The next one is the victim whose mouth is masked and unable to cry for help and the top of it looked to me like a large object that was going to crush him. Although it looked like an apple too. It looked like it was larger than the person and I felt threatened by it.

S.: The many times in my life that I’ve been physically restrained and not been able to help myself.

S: This one was the happy child playing and feeling completeness.

S: A9. This one looked like a puppy dog to me. It reminded me of him.

Dr.: Of B. (Interviewer‘s dog…calm pets reduce a responder‘s test anxiety).

s: Yes, B. It reminded me of B. and there was comfort in that because I felt that this particular puppy dog knew that I was hurting inside and he was also sad.

Dr.: Come here, Buddy. Let’s get a little shot of him in the video here. Come here, Buddy (Animals are supportive in stressful interviews).

S.: This is the real therapist.

S: The next one was a person whose eyes were out of focus. That’s the way I felt when I went into the Posttraumatic Stress Disorder. I really identified with that.

S: A11 looked like a child’s drawing to me, scribbling because they were mad and I felt relief because I had scribbled out that anger when I looked at it.

S.: An ear. It made me feel cared for. It represented to me that someone was listening to me. Someone was actually listening to me, being attentive.

S.: Yeah. I really experience that with her. Number A13 was my mom, the hand reaching out that was trapped. The one that we spoke of that was distressing.

Dr.: A14?

S.: A14 looked like a womb to me. And I was worried because the baby didn’t look normal.

S.: That it was sick. A15 looked like a womb to me of a dead baby, an embryo.

T: The way I’ve been feeling inside. (There is much age regression in individuals experiencing emotional pain).

S.: A16 looked like a symbol of healing. Two birds and a heart. A wounded heart but then there was rain coming down which represents growth and nurturing and two birds that are fluttering represents spring. I felt like it was just hopefulness in spring time in the drawing.

S.: Scabs on the outside and the inside is fresh and new and the scab is falling off and it’s being reborn.

S.: It means healing.

S.: A18 is my heart, looked to me like my heart inside, deformed from sin and suffering and I felt great compassion in looking at that in particular.

Dr.: A19?

S.: A19 looked like a serpent that was leaving, not coming to me but leaving and I felt great relief in that they weren’t coming to me.

S.: Symbolizing a change of life, a change of the way of thinking, a change of the way of doing things.

Dr.: Getting out the hurt and the anger.

S.: Getting out the hurt and.

Dr.: You’re going to feel better. A20 please.

S.: Unity of two souls still in the womb. It looked like twins to me and in a uterus. Oneness, I felt oneness looking at that.

Dr.: A21?

S.: It looked like a joyful transformation of my heart, getting ready to be free and flying. It looks kind of like a bird with a heart in the middle getting ready to take flight.

Dr. That’s what you are.

S.: I identify with that bird, yes.

Dr.: A22.

S.: I am the tunnel and this is the crisis that I’m coping with is what I felt. I felt really weary, really heavy, real tired.

S.: I felt like, it looked like a bone. I felt it was more danger, another threatening thing.

Dr.: A 24?

S.: Spilled paint on a pallet. Also it looked like a woman’s legs and inside of her vagina and it made me feel uncomfortable.

S.: Because the spilled paint, I felt that there had been an accident and then I felt uncomfortable with the fact that it looked like a woman because she looked like she was in pain.

Dr.: A26?

S.: A baby sleeping. Very, very safe, secure, very happy with that.

Dr.: A27?

S.: Lying in the flowers naked and I identified with that, freedom like the little child, unafraid and playful.

Dr.: A28?

S.: A muscled arm and wrist. The hand of God. I felt like it was a hand reaching down to rescue.

S.: At first it looked like something to fear and then I realized it was just a shadow, my imagination, nothing to fear.

S.: A skull, death, sickness. And this is what interested me about that. I felt total and complete relief looking at that. Like the torment is over, the pain is over, the weariness is over. Like I’m finally at the end of my journey and now I can go play.

S.: A man and woman brainstorming, teamwork. A feeling of being helped and cooperation.

S.: Two people cooperating for a common goal. Me and D. for my healing or for a project we’re working on or the inner reaction between me and my therapist.

Dr.: Don’t you feel good having D. giving the support and be present and that he’s going to be more involved as it’s explained to him.

S.: Yes, I feel wonderful about that.

S.: This looked like a demon to me. It looked like a fire and a demon and potential danger. ( A direct projection of dream symbolism).

Dr.: B2?

S.: A volcano erupting and I felt concern over that. B3 is two souls being taken to hell by rebel angels. That’s what that looked like to me.

S.: I felt great sorrow. It brought to me the realization, conscious realization of my accountability before God for my actions and the total end results which ultimately will be what I do here now.

Dr.: B4?

S.: Death of a mother and child. It looked to me like a mother and child’s death. It brought to me sadness.

Dr.: B5?

S.: Boy and girl in seats, pictures on the wall. Both unhappy. They’re both disturbed because they’re Black.

Dr.: B6?

S.: Fantasy, mushroom, umbrella tree. It looked like something out of science fiction. It looked very comfortable like I wanted to go sit under it, pick some of the leaves off and just sit there.

Dr.: It’s important that you get out and enjoy the beautiful weather of Maine and all that. That can heal us too, S., you know? I’m going to be out on my mountain bike in a few minutes.

S.: Good for you. Sounds real good.

Dr.: B7

S.: B7. I was delighted with this one. It looked like a jelly fish and some leaves in some water and I was ready to jump in (laughing).

Dr.: B8?

S.: The world. It looked like the world alive and breathing but I was disturbed by it because I’m not used to seeing the world throb. And that was out of character from what I normally see.

S: Two stomachs and a larynx with indigestion. I felt real discomfort like too much Mexican food. (Pathological anatomical responses relate to somatic symptoms experienced).

S: Anxiety.

S.: Yeah, I think I do. See I’m not that in tune with my body.

S.: Child’s drawing of a critter and a woman’s legs with a vagina with a cut. At first glance it looked like a Panda bear. At a second glance it looked like a pair of legs and I was alarmed by it because it looked like the particular woman had been cut. (Pathological sex anatomical response consistent with past abuse trauma).

Dr.: B11?

S.: B11. And area on my shoulder that is sore. It looked like the back of my shoulders, if you used one of the cameras that show the heat. Heat sensing camera.

S.: My shoulders would look like that.

S.: Yeah. All the time.

S.: Lettuce, onion, celery by the road in the sun like I was happy. I felt like I was on a farm and that I was ready to go pick some vegetables and sit down in the sun.

S.: A woman found in the water. I was happy that I was in the water again just like the jelly fish and the leaves and that was like a treasure I’d found.

Dr.: B14?

S.: A glass with smoke in it. I was, it felt like there was potential danger there.

Dr.: B15?

S.: A person under brutal attack. It looks like their face had been sliced off or they’d been hit by something. There were lots of knives in the picture. (Imagery depicting past exposure to violence).

S.: Fear, anguish.

Dr.: B16?

S.: A concern, another crisis but one that’s been tamed or is controllable and I felt relief.

S.: The one that I liked. A heart filled and growing with love.

S.: B18. Another on coming problem that is controllable. I felt confidence.

S.: That was the one that was threatening to me about our marriage.

S.: The healing of the brain. I felt relief and happiness, psychological healing. It was, it looked like a brain but it had green in it like it was going through a transformation.

S.: A squashed gun. It looked like somebody had polarized gun. It would that, whoever, whatever was going to do, whatever they were going to do there was a victory and it was all over with and I felt determined joy and a victory over that.

Dr.: B22?

S.: A person barely alive waiting for help.

S.: Yeah, but in this I felt total trust.

Dr.: Yeah.

S.: Total trust that help would come.

S.: A blackened lung and inflamed ribs and it made me feel uncomfortable and reminded me of somebody with asthma or smoked a lot of cigarettes or something. My son has asthma.(Projected health concerns regarding her son).

S.: Not any more. He’s gotten better.

Dr.: B24?

S.: Decayed lungs. It looked like lungs that were passed help. I felt sorrow.

Dr.: B25?

S.: A hole in the universe. I felt fear and anxiety.

Dr.: B26?

S.: Spilled lotion and the upright, up righted bottle of lotion next to it. I felt concern about that.

Dr. B27?

S.: Two embryos, one is dying and the other one is already dead. I felt sorrow (repeated death themes related to her inner psyche core of sadness, loss and depression…an opportunity to explore suicidal ideation not pursued here).

Dr.: B28?

S.: A mother saving a child from danger. I felt fear.

Dr.: B29?

S.: A child running into danger. I felt fear. (Age regression again).

Dr.: B30?

S.: Two ears. Two people being attentive. This was a situation where a person needed to be listened to. What was going on was very serious and I felt concerned, very concerned for that person.

S.: A family hiding in a safe place. I felt anxiety because this looked like a family that was in a place of warmth but they were there. Safe and security because they were frightened and it was a place of refuge.

S.: About my family at this time? We’re getting there because my husband is participating now.

T: Oh yeah. I was surprised at the drawing, A11, looked like a child had scribbled and I felt real relief like I needed to sit down and just do some real scribbling.

Dr.: Right.

S.: And I’ve had this, on the back side of my house is a home but it needs some repair work done on it so on the back side, it is going to need painted and some wood but in the mean time there is this whole bottom half of a house, it runs along the whole side of the house, there’s no windows, this has got plywood on it and I thought, “hey what a great place to do a mural.” Now I’m thinking what a great place to do some scribbling.

S.: I think I’m going to.

S.: That one with the fungus was the only one in particular that I identified with a dream.

S.: For about three months.

Dr.: And it’s come on during the period that you’re working in therapy.

S: Um huh.

S.: That I’ll be abandoned to stay this way.

S.: When we were beginning to talk about what happened in that session I was starting to feel disoriented again.

S.: Yeah.

Dr.: Good. Well, thank you. I think we’ll chat with Ken for a moment or two.

S.: Okay.

Dr.: Appreciate your involvement and I hope you do get out and enjoy that pretty afternoon a little bit.

S.: I intend to.

Dr.: Good. Thanks.

S’s Husband:

We appreciate your coming in, D. Tell us a little bit about the interview the other day with S. and J. You were sitting in on that. That must have been quite an experience.

D: Well there were a couple of interesting things. One especially in light of what happened; S. said she and I were talking about her childhood.

Dr.: Yeah.

D.: Which in fact she related what we were talking about to her childhood. We weren’t really talking about childhood. What we were talking about was some of behaviors, towards me, that she has and at the time there were several I think. I was doing the talking at the time this happened. We were talking about that she has this real strong need to have my love for her affirmed and affirmed through actions.

Dr.: Um huh.

D.: And it has to be not just that you do things for me but there’s sacrifice involved. It has to be continually reaffirmed. You can do things, to demonstrate your love, you know, ten times but if you fail, but if you fail on the eleventh time there’s going to be a lot of anger and stuff and you feel pretty much shows, that reaffirms to her that you really don’t love. And she was saying to J. she felt like I really didn’t value her and I was talking a little bit about that and how that was really hard for me because in fact that I did and that I had done things to demonstrate that. And that was the one thought that she, the one thing that she was able to write down was that my husband does value me. But it was in the midst of talking about that it was like, it was like someone flipped a switch, it wasn’t like she gradually fell into this, it was like one minute she was fine and the next minute all these physical things were going on.

D.: Well, when we went to leave it was the nearest thing I can compare it to be when we had our son she had to have a c-section and it reminded me of the first time we got her up to try and walk. And she was in so much pain and stuff, and if you see patients in the hospital, you notice they’ve had surgery and they are walking around trying to, you know, expedite their recovery and they shuffle real slowly because it’s so painful and.

Dr.: Yeah.

D.: They’re stiff and real slow and like they’re reaching out for a wall and even if it’s not there something to hang on to.

Dr.: Real Shaky.

D.: That’s what she was like and I had to, had to hold on to her because she couldn’t have walked on her own. Or she would have gone down.

S.: Numbness, like she had a cloud over her.

D.: Well, when I say numbness I’m thinking not so much physical in a sense of touch but mentally.

Dr.: I see.

D.: And her mental faculties were numb and she seemed distant like she was kind of off somewhere else.

D. No, it was obvious it was all related to what was going on. It wasn’t fear for her physical well being. I was concerned for.

D.: Yeah, plus it emphasized that the depth of what was going on, had gone on in her childhood and everything. The severity of the whole situation. I don’t think I’ve ever been around … I’ve been around people that have been in that state but I’ve never been in a situation where I’ve seen someone just go from one to the other in a matter of seconds.

Dr.: If you didn’t have the understanding of the psychological context of the interview though, you can imagine how you might feel something physical was happening to you like a stroke.

D.: Oh, yeah, something.

Dr.: Or an epileptic seizure.

D.: I have a better understanding of the extent of it and depth of it, that it’s more extensive than I realized or appreciated before.

Dr.: And the need for you to be with her and reassure her of your love and all and that you won’t abandon her and all this.

D.: Yeah, that’s one thing she’s, over the years she’s had a lot of dreams that reflected that fear of abandonment.

D.: She’d have dreams where she was in it and if I was in the dream, it would be in the context that she would be gone and I would ignore her or I would be with another woman or something else or I would be leaving or not ever expecting very, very rare that we were conscious that we were together in the same dream. And there’s not.

D.: That it’s, she had this deep fear of that, that she’s going to lose my love for what we have.

Dr.: What would you like to tell her to reassure her? She can hear us now.

D: I think the fact that I’m getting involved with her therapy stuff that it’s real critical to her because she vocalized it a lot of times. The fact that I’m involved, she sees that as a response more than anything else.

Dr.: Yeah. And you’re doing that because you love her and you’re going to stick with her and all that.

D.: Yeah. Plus the fact that you can’t, I don’t think that in a marriage, that you can separate one individual from the other, obviously they are both intertwined and they affect each other so.

D.: I don’t know if any of the questions I have can be answered. I mean it seems like the same questions we all have.

Dr.: Well, look, I appreciate very much your coming in and the same as I said to her, go play. It’s a beautiful Maine day and it can be healing to be outdoors and thank you very much for.

D.: Right. Thank you for your help.

The person has experimented with all kinds of drugs, lot of alcohol, cocaine and marijuana for the last 25 years and it has finally caused his marriage to break and lost his family. The SIS images were helpful in processing the pain and hurt, neglect…basically no emotional support which he caused to his family and now regret and grieving.

The Somatic Inkblot Series was administered to a 16 years old girl, studying 10th grade with complaints of fits of unconsciousness, convulsive movements, severe headache, low mood and nausea. She was diagnosed as a case of “Dissociative Convulsion Disorder” as per ICD-10. The SIS response projected her poor interpersonal relationship, pent up aggression, physical abuse and disturbed family functioning. The SIS-II images were used as therapeutic intervention tool with positive change in her condition and the responses given by the subject are discussed in this case study.

The patient had been a good, sincere student, praised by her teachers and always secured fourth or fifth position in her class among 40 students. All of her birth and developmental milestones were normal, with no past history of any behavioral, psychological and neurological problems. However, her parents were not satisfied with her achievements and compelling her to get first position. None of the parents supported her on any issue except her younger brother, who used to solace her in times of distress.

Her symptom started four months earlier when she took admission in class 10th. As reported by her parents, she had frequent fits of unconsciousness with severe headache and restlessness. During his pre-board examination, she became very anxious, and often used to cry. She had a love relationship with a 23 years old person who got married and left her. When she thinks about her lost love relationship, she becomes more anxious and suffers from severe headache with fits of unconsciousness. She further developed problems in her fingers and could not write the answers in the examination.

She was referred for psychological evaluation and therapeutic intervention. On psychological assessment it was observed that when she failed to solve a problem she will develop muscular rigidity which will improve/disappear after someone helped her in solving it.

During therapeutic session, she expressed severe concern about the punitive reaction of her parents of not securing the first position in the class. In addition, during therapy, she also indicated the abusive relationship between the parents. She further reported that her father frequently abused her mother verbally as well as physically. He is also an alcoholic and would not pay any attention to children.

Current Symptoms:

Her presenting symptoms at initial psychological evaluation included nervousness, shyness, severe headache, convulsive movements, clenching of teeth, low mood etc. She had poor self image and lack of self confidence. She was diagnosed a case of Dissociative Convulsion Disorder as per ICD-10. Her attacks were pseudo seizures. On EEG and CT scan no abnormality was found in cerebral activity.

SIS Responses:

Three Most Liked Images:

A7: “structure of a girl in dancing position” is normal response suggesting his ego strength and positive attitude towards life.

A14: “A pretty girl sitting on a lonely beach with sad mood” indicates her pensive mood and feeling of loneliness. In the detailed enquiry her psychotherapist may ask her do you sometime feel this grief like this girl.

B29: “A girl coming home from school and looking very happy” may indicate her wishful thinking to have a happy home during childhood which she never had. This may also indicate her regression and wish to be a school going girl to avoid problems. In the detailed enquiry it should be suggested that if she participate in the therapy, she will become like this happy girl.

Three Least Liked Images:

B 31: “People standing close, arguing with each other, a bad practice” this image brings out the imagery of “Happy family (Father, Mother and two children) but she has avoided seeing a happy family because of the broken / disturbed family relationship. This reminds you of how you feel when an argument in your family.

Analysis of a few significant responses:

A 5: “A broken and painful heart” may indicate her depressive feelings about her lost love relationship.

A 13: “Helpless hand is approaching” may indicate her pensive feeling towards life. She also needs support and help. Here she may be asked directly when she feels helpless of herself (may be recall certain theories of depression based upon to learn helplessness).

A 29: “Looks like an evil thing straight out of a horror film I saw earlier.” The image on A29 is more like TAT’s blank card which works as pure projection and the imagery of “Evil thing and horrifying thoughts” suggest her traumatic memories. Here question may be asked directly about any post-traumatic dream which she may be experiencing. It is always important, whenever possible to link her inkblot responses to her disturbing symbolic “nightmares”.

A 31: “A man and woman talking with each other, something serious”. This may indicate disturbed relationship either with her boy friend or among parents. Question need to be asked in this regard what brings to her mind.

B 3: “Hearts once broken never heal.” Once again the broken heart concept has come back suggesting her pessimistic and depressive feelings of broken love relationship. Her psychotherapist need to suggest that while she feels hopeless with her broken heart, that psychotherapy may help her.

B 4: “I never fulfilled my desires in this atmosphere” may indicate her dissatisfaction particularly in the family.

B 6: “A sad girl in mirror” indicates her own sufferings and grief ridden unconscious material.

B 15: “Please stop this violence for GOD” suggests that she is fed up with violence in the family. Her repeated instances of being exposed to angry and violent family scene likely played a role in her muscular skeletal symptoms. Certain vulnerable women inhibit the expression of their own inner rage by psychomotor skeleton muscle inhibition. This mechanism has been referred to as “Character Armored”.

B 19: “Burning sun and broken heart, how sad, no one gives protection”. This may suggest her broken love affair and broken home with feelings of hopeless and helplessness. Her therapist might well question her in regard to possible suicidal ideation which she has not reported given the intense feelings of hopelessness and helplessness.

B 28: “Woman in distressful situation” may indicate her sympathetic feelings towards her mother as well as her own personal anguish.

Interpretation of SIS Responses on Re administration (After 14 sessions of Psychotherapy):

Response to three most liked Images:

A 7: “A girl in dancing position, trying to catch the apple” is a good response suggesting her ego strength and positive attitude towards life. The dancing position is improvement of her earlier mood prior to psychotherapy.

B 31: “Father Mother and two children, nice picture with whole family” also suggest improvement and positive change after therapy.

B 29: “A girl wins in a race competition”. She has moved from an aggressive and hostile attitude to make success in life is a positive change.

Following therapy a dramatic improvement was observed in the images previously labeled as least liked for example, see B31 and B5.

Analysis of other significant responses:

A 3: “A beautiful fairy with magic stick coming from sky to resolve human problems”. This response indicates her hope and optimistic thoughts for life. It indicates that the supportive psychotherapy has made positive change.

A 5: “Eagle catching a heart” although she still retains some heaviness and sadness in her heart, it is being reduced symbolize by Eagle catching her heart and flying upwards out of her past pain.

A 1O: “A girl sees her face in mirror and smile on herself”. This response indicates her positive ego strength and changed mood in comparison to her perception on this image at initial testing. It also indicates that the therapy has helped her to solve her problems and develop positive attitude towards life.

A 13: “A powerful hand capable for security” indicates her positive strength and self confidence.

A 29: “A picture of a hill station” indicates her happy mood and feeling of enjoyment.

A 31: “A girl is smiling and a boy in sad mood” projects her improved state of mind in smiling shape and wishful thinking to see her ex-boy friend in agony and sad mood.

B 3: “A girl giving answer of some difficult questions” This is the direct projection of how certain of her psychotherapist’s questions have caused her to face the painful emotional issues involved in grieving the loss of her love relationship.

B 4: “A mother and child” is an improved normal response in comparison of earlier projection of depressive response on this image.

B 5: “A boy and girl playing with ball” is a good response indicating her happy mood.

B15: “A picture of many grasshoppers and spade like knives” is again an improved response in comparison of earlier aggressive response on this image.

B19: “A bug/ sun” is again a normal response though he gave depressive response on initial testing.

B 28: “A mother hugging the child” indicates good interpersonal relationship particularly with mother.

Treatment plan:

The long term treatment plan involved improving coping strategies, family intervention and supportive psychotherapy supplemented by SIS symbolism in therapeutic process. The combination appeared to have marked therapeutic effects and the family members have also noticed considerable improvement after therapeutic intervention.

The SIS Booklet form was administered to a 16 years old girl, studying in class 10th with presenting symptoms of nervousness, frequent headache and convulsive movements, initially and after 14 sessions of psychotherapy. She had low self esteem and lack of confidence. Her response on Somatic Inkblot Series-II reflected her disturbed family relationship and unexpressed “inner cry”. Her responses on re-administration changed significantly. The SIS symbolic interpretation helped her in recovering from the stressful family situation.

Transgender is a general term applied to a variety of individuals, behaviors, and groups involving tendencies to vary from culturally conventional gender roles. Transgender is the state of one's gender identity (self-identification as woman, man, neither or both) not matching one’s "assigned sex" (identification by others as male, female or intersex based on physical).”Transgender" does not imply any specific form of sexual orientation and such people may be identified as heterosexual, homosexual, bisexual or asexual (Layton,1966).

The word transsexual, on a scale called the “Benjamin Scale” defines different levels of intensity of transsexualism, namely, "Transsexual (nonsurgical)", "True Transsexual (moderate intensity)", and "True Transsexual (high intensity)". Many transsexuals believe that to be a true transsexual, a person needs to have a desire for surgery, however, it is notable that Benjamin's moderate intensity "true transsexual" needs either estrogen or testosterone medication as a "substitute for or preliminary to operation (Benjamin, 1966).

In addition to the larger categories of transgender and transsexual, there is a wide range of gender expressions and identities which are contrary to the mainstream male-female binary. These include cross dressers, transvestites etc. The current definitions of transgender include all transsexual people, although this has been criticized. Intersex people have genitalia and other physical characteristics that do not conform to strict definitions of male and/or female, but intersex people are not necessarily transgender, since they do not disagree with their assigned sex at birth. .

Case Mr. X:

Mr. X, 30 yrs, male, unmarried, Bengali speaking was referred by a physician to a private psychiatric hospital in Calcutta for multiple symptoms. The main complaints of the patient was gender identity crisis, too much interest in sex-changing surgeries, feelings of being harassed by teasing of peers in childhood, attempted suicide (thrice), unpleasant past experiences, disturbed sleep, distress in working condition, poor job satisfaction, lack of peace/low mood, anger/irritation, worry about future and low self-esteem. He has severe depression, hopelessness and frustration towards future life.

His father died in early childhood and he was brought up by his mother in his maternal uncle's house. He is the only child and has good relationship with his mother. Her mother is a working woman and is unable to spend enough time with him. Others in the family are not that much co-operative. Most of the people use to tease him for his sexual orientation by telling him that he looks more like a girl than a boy. He was also teased by his school teachers and friends on his sexual orientation. He was abused sexually by a few known friends initially but later on he had consensual passive homosexual involvement with them several times. His friendship breaks up easily causing him to often have relationship crisis.

The Somatic Inkblot Series-II (SIS-II) was administered to him following the standard procedure (Cassell and Dubey, 2003), for understanding his personality profile and unprocessed unconscious material needs to be addressed during psychotherapy. He was motivated and cooperative during testing. The clinically significant responses on SIS-II are discussed ahead:

A1: He perceived “butterfly” on this image which is not a common response. The butterfly may indicate feminine outlook and interest in feminine objects.

A2: He saw “Heart” on this image which is a atypical response that may depict body imagery and to some extent signs of tension and anxiety.

A3: “Cloud” may indicate his free-floating anxiety on this image.

A4: Perceiving “Chocolate” on this image may suggest regression to childhood and feministic attitude.

A5: He has viewed “Birds” whereas human figure is the most common response which he has avoided. This probably indicates his disturbed interpersonal relationship with others.

A6: Perceiving “Toy” may again bring the theme of image A4 and his regression to childhood to avoid problems as an adult.

A8: He has perceived “Planet” though male sex organ is the most common response on this image. Avoiding male sex organ may indicate his deep rooted sexual conflict which could be due to faulty gender perception or disturbed sexual role as passive homosexuals.

A9: He viewed “two Insects” whereas two human beings - a male and a female - is the common response on this image. Avoiding two persons may again indicate disturbed interpersonal relationships particularly between male and female.

A10: “Eyes” is generally perceived normal response on this image.

A11: “Meat (chicken)”is a passive, aggressive response which may indicate helplessness, frustration and depression. The dead chicken (meat) may also be taken as strong indication of suicidal tendency, which the patient has already tried thrice.

A12: Perceiving “Eyes” on this image may indicate his suspicious attitude toward others which needs to be addressed during his therapy sessions to explore the possibilities of paranoid tendency if any at this stage. He is unable to continue friendship with anyone which might be an early indication of some serious pathology.

A16: “Small Sparrows” is a beautiful response though most people perceive it as two birds. “Small sparrows” may again indicate his regression to childhood where he feels comparatively more secure.

A17: “Cage” may indicate his feeling of helplessness and inability to come out of his present situations.

A21: He perceived it to be a “Star fish.” Though a tortoise / a big man with two babies are the common responses on this image, avoiding two babies and big man may indicate his perpetuator who had forced sexual abuse during childhood.

A22: “Star Fish, Sea Fish” might indicate his conflicts with gender role as the common response on this image is Spinal Colum which represents male phallic organ - a conflicting area of the patient.

A23: He perceived “Scorpio” which is considered to be a painful insect though Spinal Colum is a common response and avoiding this response indicates his conflicts regarding male sexuality which is the main problem of the patient.

A24: “Leg Joint” is the normal response on this image.

A25: “Female sex organ” is a normal response on this image. Perceiving female sex organ might indicate his wishful thinking to identify this image as his own body part by taking help of surgery.

A26 “Babies in pregnancy” is a normal response on this image.

A27 “Female Breast” is a normal response on this image. It may indicate his good interpersonal relationship and closeness with his mother.

A31: “Two faces” is a normal response on this image though a male and a female have been a better response. Avoiding male and female may also indicate his gender role conflict.

B3: He has perceived “Clouds” on this image though people talking are the common perception. The cloud may indicate his tension and free floating anxiety.

B8: He has perceived “Nose” on this image which may be an indicator of homosexuality.

B14: He has perceived “Water” on this image though this is a rare response which may represent anxiety and insecurity.

B16: He viewed “Scorpion” on this image which may repeat the theme of his perception on image A23. The spinal cord is a common response on this image and avoiding this probably indicates his conflicts regarding male sexuality.

B18: He has perceived “Insect” instead of a “male phallic organ” which is most common response on this image. Avoiding perceiving the male sex organ and perceiving it as an insect may indicate his conflict in the male phallic region.

B19: “Sun” is a normal response on this image but avoiding two hearts (either side of the sun) may indicate frustration and his conflicts in interpersonal relationship.

B22: He perceived “Frozen Man” which is a very depressive response. The therapist must take note of this during therapy session to address severe depressive contents with the help of antidepressant drugs and psychotherapy. This may also indicate severe suicidal ideation.

B27: “Twins” is a normal response on this image.

B28: “Mother with a baby” is a normal response on this image. It further indicates his close relationship with his mother.

B31: “Family” is a normal response on this image.

As whole SIS responses indicate that he has contact with reality, has moderate ego strength and is free from psychotic ailments (no psychotic features). However, he has shown severe suicidal tendency, poor interpersonal relationships, conflict in the sexual area and gender role with marked depression and frustration. He was treated with the help of drugs and psychotherapy with significant improvement.

Stimulus Plate SIT-20: Dangerous Impulses / Visceral Boundary Assessment

Behold and see as you pass by

As you are now so once was I

As I am now soon you must be

PREPARE for death and follow me

If this old tombstone engraving activates death wishes in your mind, be forewarned. This article is designed for training students in SIS technology for detecting, otherwise unreported, suicidal/homicidal ideation. Clinical case examples follow as a teaching demonstration to illustrate how this projective technique brings to the surface material otherwise hidden from standardized clinical interviewing. These will empathetically expose a reader to the inner cry of suffering souls attempting to release their pain through violent acts - either directed to themselves or others.

Realize that humans exposed to violent scenes, either through direct experience, or otherwise such as even while reading, can become secondarily infected. Moreover, those with unresolved personal issues, whose inner world has a depressive core, may be especially vulnerable. This vulnerability is due to their painful unresolved issues. If the tombstone prescribed “preparation” activates death wishes for readers, be forewarned when training for a career in the mental health field (De Angelis, 2011).

All Mental Disorders are associated with higher suicide rates (Nordentoft, et. al. 2011). For example where data are available, individuals with a history of Major Depression are about twenty times more likely to kill themselves than the general population. (1) Rates increase substantially in those also suffering from co-morbid conditions such as PTSD and Panic disorder (2). Often the association with substance abuse contaminates the data (Fazel, et. al. 2009; Harris and Barraclough, 1997). Moreover some conditions such as Schizophrenic Disorder have higher rates of homicide (Erb, 2001).

Regarding the former, there are screening instruments available such as the “Patient Health Questionnaire and the Quick Inventory of Depressive Symptomatology”. However, there are no data to evaluate their effectiveness. Consequently most clinicians rely on standardized interviews. In this regard there are several assessment criteria based upon completed suicides (Gaynes, et. al. 2004). Some examples follow: men are three times more likely than women to kill themselves, physicians are at elevated risk, particularly women doctors, single people who have never married, those having a failed relationship the preceding year, hopeless individuals and psychotics with auditory hallucinations (especially with command voices to suicide).

Yet sometimes severely suicidal individuals pass undetected “under the diagnostic radar screen”. Unfortunately this failure may occur despite detailed clinical interviewing. Then such ‘masked”, unreported self destructive impulses only become evident in retrospect, after an unexpected suicide. Retrospective postmortem studies reveal that in the days preceding death, a significant numb of victims consult care providers. These professionals may have to face not only their irrational guilt from such failure, but sometimes angry relatives threatening litigation.

Such violent behavior might be prevented in the future, if the care victim’s care providers had included in their initial diagnostic workup a version of the Somatic Inkblot Series (SIS). When assessing dangerousness, SIS projective testing enables the examiner to bypass psychological denial defenses. (Otherwise hidden suicidal symbolism can emerge as an alerting warning).

Four clinical case histories will be presented to illustrate this aide to standardized diagnostic interviewing.

The first two cases illustrate how the projection projecting of a “Weapon” response may signify self destructive impulses denied in interviews. The third case reviews SIS responses depicting “severe sadness”,

body injury, blood or death in an individual “wishing to die” but denying a conceptualized suicide plan. The fourth case illustrates bizarre dangerous SIS responses, frequently found in the early unmediated stages of an impending schizophrenic breakdown.

Stimulus Plate SIT-5: Butterfly / Contoured Bilateral Symmetry

A 14-year-old high-school, epileptic girl was readmitted to a psychiatric hospital upon transfer from an intensive care unit in a general hospital. She had just recovered from medically overdosing of an anticonvulsant drug. When this initially failed, before she became comatose, she slashed her wrists.

She was known by the hospital treatment team, since ten months previously she had been treated for severe suicidal Major Depression. Her depressed mood recurred after she stopped her antidepressant medication as well as follow-up psychotherapy. It began one week after the accidental death of her two favourite grandparents. She made her almost lethal suicide immediately after arguing with and then physically assaulting a girlfriend. Afterwards, she felt rejected and wanted to die.

Later in the psychiatric hospital, she initially denied having self-destructive impulses. She claimed that she had simply overdosed so as to "go to sleep” and forget about her emotional suffering. Yet on further questioning, she readily admitted “That when the pills didn't kill me, I slashed my wrists in order to die”.

As part of the admission assessment, she was asked to complete the following sentence completion tasks:

Sentence #1: "I worry a lot about ". She responded "losing family and friends". This was a direct reference to the recent death of her grandparents and rejection by her friend.

Sentence #2: "Sometimes I get angry because ". She responded "I don't want people to see that I am hurt or sad". Later she cited that this was the reason that she had become so angry with an empathetic friend who persisted in questioning about her grief.

In cognitive psychotherapy, to facilitate her grieving losing her grandparents, she was asked to write a goodbye note to each. Previously she had been unable to say “goodbye” directly, since her grandparents had lived outside of Alaska. She wrote the following: “Nanny: I wanted to say one last goodbye. You always wanted things to be done your way. I guess that I am a lot like you. You helped me grow into what I am today”.

Granddad: “I remember going to the farm. I remember Kansas. I guess all I wanted was to say goodbye. Thanks, and I love you." During such psychotherapeutic sessions, she realized that her previously unexpressed anger related to their loss.

Direct images of suicidal behavior surfaced in art therapy as she drew “a girl with a gun pointed to her head”. When questioned about the projected imagery, she emphatically declared "It's not me but someone trying to take pain away!" This dramatic denial, in the face of the overt reality of her drawing, reflected her mental defence mechanisms that still intermittently persisted in order to protect her conscious mind from experiencing painful grief.

With regard to the SIS Video, in viewing B22, (illustrated on our SIS web page at www.somaticinkblots.com) she failed to recognize the embedded SIS form/structure depicting “body resting” or “a person dying… with the spirit leaving the body”. Instead she projected the response, "A gun under water”. Her failure to recognize the human body reflected a mental mechanism of Dissociation from her own Body Gestalt, to avoid the somatic based painful affect.

In terms of the time sequence of psychobiologic events, as a conceptual model it is proposed that when she first looked at B22, the physical rays of light likely left patterns on her retina probably approximating, yours as a reader, now viewing the inkblot. However, unlike your brain based defence mechanisms, when the light sensory input was transmitted by her optic nerves to the visual centers in the cortex, then relayed to centers appraising threat, they were interpreted at a preconscious level as too threatening. Consequently their somatic connotations were actively blocked by the inhibitory central nervous system neurons.

Next after this first step in perceptual inhibition or “repression“, over the normative SIS inkblot cognitive interpretation, her central nervous system’s based defensive mechanisms - in a yet to be studied by neuro-imaging technology - secondarily substituted the disguised symbolism “Under Water”. This effectively blocked recognition from awareness and cognitive recognition. (Previous SIS work has shown that if this blocking mechanism persists in psychotherapy, it can be dissolved psychologically by hypnotherapy, and if highly resistant, by pharmacological agents such as intravenous barbiturates). In any case, the final step in this defensive sequence involved the projection of a Weapon response. Clearly, like the figure drawing described, this revealed that she had experienced impulses to end her life by the terminal physical act of shooting herself or conceptualized concretely, as shooting the vessel that she lived in (i.e. her body).

In such clinical cases, it always remains a challenge in the detailed enquiry for the examiner to establish, such a symbolic response time referents (i.e. were they just in the past prior to her almost lethal overdose? Or were they still lurking in her mind, but being denied assessment interviewing?).

This conceptual model illustrates the manner in which analyzing SIS responses enables the examiner a living lens through which to peer into otherwise invisible mental defence mechanisms. While the SIS electronic video/computer technology reveals more of the suicidal individual’s inner world than with Figure Drawings, assessing fluctuating illusive suicidal impulses constantly requires all of the clinician’s skills.

Stimulus Plate SIT-1: Core Somatic Grief / Central Structural Focus

This 15-year-old Alaska Native girl was admitted to the psychiatric hospital with a long history of severe recurrent Major Depression associated with suicidal and homicidal ideation. Her SIS Video responses will be first presented in order of the three written responses that she subjectively rated as “Least Liked”. These were as follows:

B15: “Different kinds of knives”. In the detailed inquiry, she said that it brought to minds “scary” memories dating back to age thirteen when despondent. During such periods, she frequently contemplated stabbing herself. Once when out of control withdrawing from cocaine, a friend came in, grabbed a knife out of her hand. This incident illustrated the co morbidity of substance abuse with dangerous impulses. Another association to B15 evoked in memory an incident at age nine, when she was severely stressed by witnessing her father threatening her mother with a knife. The third episode violent recollection involved an assault with a knife that she made at age 13. Then during a fight she attempted to kill a girl who ran away and was only stabbed in the back of the leg.

B22 was the second most threatening affect charged response. This brought to mind “Something dropping on a person… or someone being put to death… It made me feel sad that the person was being killed slowly”. She had recently been in a high school English class, where 'the culturally sanctioned punitive act of stoning a sexually unfaithful woman was acted out in a psychodrama class. She had to play the victim’s role. In view of her PTSD history, this was a questionable request by her female teacher. In any case, it proved “Quite upsetting!” since the violent death scene played out brought to mind her persistent dangerous ideation.

B12 evoked the third most “Disliked” SIS imagery: “A person with a migraine”. This reminded her empathetically a female peer in the hospital suffering from migraine headache. It also brought to mind her 17 year old sister who suffered from frequent disabling migraine headaches. Thus her (SIS) activated recollections revealed that in spite of her grave issues; she had a capacity for empathy- a positive projective prognostic sign.

Concerning the three blots that were rated as most “liked”, the first was A16 imagined to be “Two birds kissing“. This showed an ability to have positive affect bonds. B19 “A mix between the sun and the earth with a heart on it”. Here she showed a mental ability to shape Gestalt responses. Her third favourite image was B25 “A mouse, because it is so adorable." These responses suggested that in spite of her psychological problems, she was able to experience positive, loving emotions for animals, and possibly for people (?). Thus these responses improved the overall prognosis regarding psychotherapy.

Now the SIS responses will be reviewed in terms of those having some additional relevance:

A24: She saw a skull that "smashed up bad." In the detailed enquiry this brought to her mind memories at age 12 of being rear-ended in an automobile accident. She hurt her knee. In speaking about this she recalled the fact that her foster mother could have been severely injured. She flashed back to the deafening sound of the impact of the care striking the vehicle she in which she was riding. What she omitted was any recollection of her previous threats to “smash the heads” of her residential treatment staff.

B2: “A lion's face that is deformed“. This is a projection not only of her aggressive tendencies but also her own self- concept. She felt herself, being somewhat “deformed”.

B4: “A mother and child, with the mother kissing the child's cheek”. This is consistent with her deep seated needs for nurturing. Much of her seething undercurrent of anger related to her having unmet childhood needs for nurturing.

B6: “Legs ripped off a body”. Here her persistent dangerous impulses again emerged in Projective Awareness.

B7: “Amelia Bedillia's head with a flower on the hat”. She imagined this to be a character in one of her children's books. This showed her feminine identification.

B11: "Smile now, I'll cry later." When asked about this, she elaborated on the way she had self- medicated with the street drugs/alcohol that is “party now and pay later”.

B28: Here, rather than recognizing the structure of a nurturing image of a mother nurturing her only, imagined it to represent “A person is thinking." This is consistent with her own impoverished and traumatic childhood. The lack of attention that her mother gave her was continuing into adolescence. This was evidenced when her mother had recently visited the hospital, yet had avoided visiting her.

Stimulus Plate SIT-7: Exhibitionism / Body Boundary Perception

This case illustrates how severe depressive dysphoria may motivate a tormented sufferer to contemplate death to escape from psyche pain, even when lacking a specific suicidal plan. Portrayed is a single suicidal woman in her mid twenties having a limited high school education? During a protracted grief reaction, hospitalization was required to protect her from dangerous ideation. Her severe depression had begun several weeks previously following the suicide of her former boyfriend “J.”. She had been traumatized during their mutually abusive relationship -especially after it ended when he shot himself.

She had classical depressive symptoms during the day. Moreover at night she was tormented by PTSD “Nightmares”. These replicated stressful scenes in their past relationship. What facilitated projective enquiry into the depths of her depression, especially her desire to die, was her compliance with therapy? As instructed, she had followed in detail, the initial SIS-II Video instructions. Thus, unlike many responders, she recorded on the SIS Answer Booklet, not only her stimulated visual impressions, but also their image linked affect.

In regard to the SIS stimulus pattern rated as most “Disliked” (i.e. emotionally threatening), she selected A23 as “A skeleton”, which represented a death symbol. In contrast when initially viewing the video pattern, she only had reported seeing: “A lot of scary lines”. It is suggested that her failure to recognize the somatic structure in the initial viewing was due to brain mechanisms protecting her mind from recognizing material symbolically related to her anxiety about “wishing to die”. Fortunately her ambivalence about herself destructive impulses, as opposed to her wishes to live, prevented her from conceiving a suicide plan, and then acting on it.

The second most upsetting scenes were visualized with A31. She said “It looks like two people depressed, lonely and thinking”, “They look sad”. The third rating in the anxiety-threat hierarchy was A30: “Looks like J. is alive and spooky”. When describing this further after completing the series, she explained: “I didn’t like the mask with eyes…looks sad”, this represents a surfacing in Projective Awareness of PTSD dream imagery replicating abusive scenes with “J.”.

Concerning the three SIS video scenes she “Liked”, these were in the following order:

A5: “A heart”. She favoured it “because it is red”. Her being able to appreciate the bright color represented a hopeful prognostic symbol.

B23: Here she visualized: “A spider with many legs…and looks like the sun”. Afterwards she indicated that the sun made her feel “Happy”.

Thus even though she was deeply depressed, she still could imagine a positive hopeful future.

B5: “Two people sitting in a chair and talking to each other”. She explained that liked it was “ two people talking to each other made her remember the good times in her past tragic love relationship. Here her projected imagery suggests the presence of communications skills - a positive prognosis sign for psychotherapy.

Now her remaining inkblot responses depicting her severe sadness and depression will be presented. In addition to the two already noted (A30 & A31), the following are examples:

Apart from depicting her depression, some of the above responses reflected her associated PTSD anxiety and sexual/reproductive issues. These were also projected in relation to several other SIS stimuli. Examples follow:

Finally, it might be noted that her frustrated desires to have children were embodied in her responses to the following inkblots: