Conceptualization of the SIS Procedure

Need for Development

Projective techniques particularly inkblot tests are especially helpful in evaluating

patients with limited language and verbal skills such as children, foreign born or new

immigrants, native peoples, the learning disabled or the mentally sub normal. There is

enough structure in many of the inkblots to provide a sense of security and a measure

of self-confidence. Those with limited language and verbal skills usually rely more on

visualization and adapt better to projective technique than verbal interviews or testing

that requires reading or language skills. Such images use the language of dreams,

visual imagery, and symbolic thought, the most basic forms of thinking and expression.

It is also the language of repression and brings whatever is buried in the mind closure

to consciousness, accessible for processing. Expression stimulated by ambiguous or

partially ambiguous imagery can be used in therapy to test insight and to help measure

treatment progress. With such strong notions in mind, Cassell started developing the

Somatic Inkblot Series.

Originally, Dr. Wilfred A. Cassell, worked with Seymour Fisher, “who prior to his death in

1996” was an authority on body perception. Cassell’s thinking, within his clinical work,

was influenced by Fisher’s work. Cassell also had extensive exposure to the Rorschach

Inkblot Test and other projective techniques. While initiating the idea of a newer test, he

kept in mind that the concept of body image projection carried through using an inkblot

technique might yield good results in the practice of psychiatry. In 1960, after an

investigation of psychological problems of women troubled with hirsutism, he developed

the first series of somatic inkblots, based on this concept.

The study led to the publication of an article on the disturbances in the body image of

women with hirsutism (Hollender and Cassell, 1965). This study, along with Seymour

Fisher’s research with inkblots on body image distortion of arthritis patients, made it

evident that there was a need for a more specific technique to measure body awareness

(Fisher and Cleveland, 1968). The author began with an examination of the Rorschach

index referred to as the “penetration score” (Cassell, 1964). This resulted in a published

study on the relationship between Rorschach anatomy responses and somatic

symptoms (Cassell, 1965).

It became apparent that there were difficulties using Rorschach inkblots to assess

body imagery and somatic symptoms because there is little somatic structure in the

inkblots. There is also a corresponding lack of interpretive material in the various

scoring systems. An elaborate scoring criteria for the Rorschach was provided by John

Exner (1969). His system is based on norms from a large number of variables such as

color, shading, form, etc. To a lesser degree, he viewed the Rorschach as a projective

instrument where content had some significance. He estimated that only about twenty

percent of responses involved “projecting” onto the stimulus properties of the inkblots

(Exner, 1989).

10 Conceptualization of SIS

The Somatic Inkblot Series, initially developed in 1960, provides images in three

forms: on cards, in a booklet and on videotape.

Somatic Inkblot Series -I: 20 Cards

The Somatic Inkblot Series- I consists of 20 inkblot images printed on white cards, each

measuring 16.5 X 20.5 cms. The images are printed in black, red, and gray (screened

black). Eight of them are black and red (serial numbers 1, 2, 3, 4, 5, 6, 7, and 8); three

are exclusively red (serial numbers 10, 11, and 12); and nine are achromatic (serial

numbers 9, 13, 14, 15, 16, 17, 18, 19, and 20). Images provide enough obvious

anatomical structure to evoke spontaneous verbalization, but not enough to limit the

responses solely to the naming of body parts or colors. In this way, obvious anatomical

structure provides a feeling of security, which makes deeper and more symbolic

repressed material more accessible to the person taking the procedure.

The SIS provides clinicians and researchers with a new diagnostic aid for body percept

assessment. It can be used to assess the depth and significance of somatic symptoms,

conversion reactions, somatic delusions and sexual dysfunction. A psychoanalysis of

mutilated or distorted anatomy responses can assess the possibility or level of castration

anxiety (Cassell, 1980). Responses depicting themes of body assault may further

clarify the extent of aggressive impulses (Cassell, 1977).

As a diagnostic tool, the series can help to evaluate undetected affective disorders.

Kielholz (1974) referred to these as masked depression, where depressive feelings

are denied during the interview and in non-projective psychological tests. The responses

to inkblots might uncover body perceptual disturbances such as in catatonia, or the

cognitive defects of early schizophrenia. Death anxiety in those facing major surgery,

or those with a terminal illness may be signaled by excessive anatomical responses

(Cassell, 1979). The Somatic Inkblot Series can be used to help design a treatment

program which might include body awareness exercises, such as physical therapy. It

also may be used in other therapies, such as sensory feedback training, behavioral

therapy, and desensitization for psychophysiological symptoms associated with

pathological anatomy responses (Cassell, 1977). This technique has been described

in the book, “Body Symbolism” (Cassell, 1980), which has been translated into Italian

and published in Florence, Italy.

Somatic Inkblot Series-II Booklet (62 Images)

In 1980, after initial success with SIS-I, the development for SIS-II in booklet form was

initiated. It consists of A Series and a B Series, each with 31 images, for a combined

series total of 62 images. There is also a sample image in the beginning. The stimulus

images are printed in rectangles measuring about 5x6 cm., each with a space provided

below the image for writing the response. All the images are contained in an eightpage booklet. The first seven pages consist of the stimulus images and the space for

responses. The last page is printed with instructions for self-administration, and a place

for a brief health history and personal data. Unlike SIS-I, it consists of images printed

with blue ink on grey paper.

The SIS-II can be used in a variety of ways, but was designed for self-administration

after supervised instruction. Some clinicians use the booklet with the patient or to

unobtrusively observe the self- administration to observe reaction times and significant

verbal and nonverbal responses for each inkblot (delays, overreaction, content shock).

Others prefer to allow the patient to take the booklet home and write in responses

whenever they have the time to relax and review the figures (intermittent administration),

or if they prefer, at one time (continuous administration). Some have found it useful to

have the patient complete the test booklet before going to bed, to stimulate the

unconscious to process repressed materials in dream during sleep. None of the existing

inkblot tests are designed to be self-administered.

Projective testing accesses information about the individual not readily available from

history taking, interview, mental status examination or from other forms of testing. It also

elicits information, which is not consciously known to the patient, or reported as a

problem. Usually, clinically significant, blocked material, will over-ride typical normative

responses directly (manifest), or it will appear in symbolized imagery, similar to dream

work (latent).

Because there is no time limit, “test anxiety” is reduced, and the individual is free to

react in his own time, often exhibiting significant verbal and non-verbal clues to each of

the inkblots. Since there is no text to read, the Somatic Inkblot Series does not require

a high reading level, therefore, it is applicable all age groups and a wide variety of

cultures.

In SIS-II, the subject is asked to rate the three-inkblot images that he “most liked” and

the three images that he “least liked.” This inquiry invites positive or negative affectual

discharge. The subject’s emotional investment provides valuable diagnostic clues to

his/her psychological function. The SIS-II can successfully identify various groups of

clinical subjects, and can be used to screen out abnormal subjects from normal subjects.

Somatic Inkblot Series II -Video

Sometimes psychological tests are threatening. Occasionally, the subject becomes

anxious or uncooperative during the testing. This is also true for projective inkblot tests.

To make the procedure more interesting and dream-like, the video version of SIS-II

was developed by Cassell in 1984. The subject’s interest is sustained by using light,

soft music, floral presentation in the background and zoom-in and zoom-out impressions.

During the experimental stages, it was observed that this innovative video technique

was quite encouraging. The rejection rate dropped considerably, the subject’s interest

was maintained throughout, and the exposure time of images became constant.

The SIS video begins with pictures of flowers and soft background music, followed by

stimulus images, one at a time. Each image stays on screen for approximately 30

12 Conceptualization of SIS

seconds. Many of the images are colored, and for some, impression of movement is

also created. Many of the images are sharper on screen than they are in the booklet.

The background music continues up until the presentation of the sample image, and

then it stops. The floral presentation, however, precedes each image. The floral

presentation, with soft background music, induces the subject to relax. Since the test

works as a time machine and takes the subject back in time, relaxation images are

presented at the end to bring the patient back to reality.

Images with human content assess the subject’s emotional maturity. For instance,

image B28 represents the mother-child relationship. Clinical issues such as patienttherapist communications are represented in image B5. Suicidal-homicidal ideation is

represented in images B15 and B21. Likewise various images help in assessing

different areas such as interpersonal relationship, healthy body imagery, erotic imagery,

self/ego strength, reality contact, hostility/aggression, insecurity etc.

Images with human content assess the subject’s emotional maturity. For instance,

image B28 represents the mother-child relationship. Clinical issues such as patienttherapist communications are represented in image B5. Suicidal-homicidal ideation is

represented in images B15 and B21. Likewise various images help in assessing

different areas such as interpersonal relationship, healthy body imagery, erotic imagery,

self/ego strength, reality contact, hostility/aggression, insecurity etc.

In clinical settings, the Somatic Inkblot Series (SIS) has both diagnostic and therapeutic

applications. In regard to the former, it has been used extensively as a structured,

projective, diagnostic procedure. Through the power of projection it can reveal material

from the inner self (Cassell,2001,2002;Dosajh,1998,1999; Dubey,2000; Kumar,2000;

Panek, 2001; Sperbeck, 2000; Verma, 1999, 2000). The 62- image series ranges from

those that are relatively unstructured, to the semi-structured, to the highly structured.

This affords the trained examiner a wide range of opportunities for the comprehensive

examination of the subject’s cognitive and emotional processes.

Research data obtained from a variety of clinical settings internationally indicates that

the clinical investigators using the SIS technology can distinguish different diagnostic

categories with acceptable levels of statistical confidence (Banerjee et al, 1998; Cassell

and Dubey, 1997; Chaudhury et al, 2001; Dubey et al, 1995; Kaur and Verma, 1998;

Kumar et al, 2001; Mitra and Mukhopadhyay, 2000; Mohn et al, 2002; Nicolini, 2000,

2002; Pandey et al, 1999, 2001; Rathee et al, 1998,2002; Sarkar et al, 1999; Cinzia,

1998; Srivastava, 2002; and Verma et al, 1999,2002). In the future, SIS derived projective

material may be included in formal psychiatric manuals to sharpen diagnosis.

The SIS has been proven to provide a useful aide to therapy by a number of innovative

clinicians (Cassell, 1998, 1998a, 1999, Dosajh, 1998, 1999, 1999a, 1999b; Dubey

and Cassell, 2000; Mishra et al, 2001; Tewari and Dwivedi, 1999; Verma et al, 1999,2001).

As more clinicians avail themselves of the SIS technology, they will be more effective at

developing in-depth and sophisticated treatment plans. One can envision an optimal

blending of information from the medical and psychological aspects of human existence.

From the physical, information input from genetic DNA factors may supplement

information derived from standard psychiatric interviews concerning choice of optimal

psychotrophic medication. Similarly data obtained from the SIS and psychological

tests of various types can help guide psychotherapy planning.

In addition, industrial psychologists have found the SIS particularly useful as a technique

for the assessment of personality and vocational ability in industrial settings

(Dubey,1993,1996,Dubey,Agrawal and Palia,2001, Dubey and Cassell,1993, Dubey

et al 1995, 2001,2002)

Apart from the above, the SIS may be used as a guide to develop personalized visual

imagery for meditation and enhanced spiritual awareness. When the viewer selects

the “three most liked images”, these can often be used as an effective visual stimulus

to induce trance-like states with their associated physiologic relaxation. Having the

subject rate the positive valence of the SIS flowers and nature scenes at the end of the

video ordinarily is a more effective way of identifying hypnotic and healing images.

These can focus consciousness away from painful body sensations and disturbing

memories of current stressors and past traumatic events. This can initiate an imaginary

trip away from immediate stressful reality into an inner world of peace and positive

spirituality. Time-space-energy may be dramatically fused paving the way for inducing

mystical connections between the self and loved ones - either living or deceased. The

individual’s spirit may rise above the relatively brief temporal reality of one’s body in

order to prepare for death and ultimate transformation into higher planes of spiritual

existence.

Once the subject has been sufficiently trained in this form of meditation, it is helpful to

work with a spiritual advisor familiar with the individual’s personal religious beliefs and

culture. Certain SIS stimuli may be particularly helpful in this regard. For example, what

is suggested through projective technique with Image B 22 depicts a dying individual’s

spirit leaving the body. After viewing this suggestion, the notion of spiritual existence

outside the physical world can be explored. The individual may be requested to recall

past dreams in which deceased loved ones have appeared living and happy in a

spiritual dream plane. This more easily enables the discussion of the subject’s death

anxiety and religious beliefs as well as the meaning of existence.

Other images may be used in innovative ways to take the subject through the various

stages of biological metamorphism. Image B 19 can symbolize the moment of

conception and the origin the individual’s body. Image A 26 depicts the intrauterine

phase of existence. Viewing this can lead to philosophical speculations about the

dawn of the viewer’s psychological and spiritual energies. Next Image B 27 suggests a

live fetus on the right and a dead one on the left. Here, the projective discussion can

explore the precarious nature of life as well as the unfairness of suffering for the

14 Conceptualization of SIS

discussion on early childhood experiences with parental figures and other past

caregivers. The same applies to Image B 31 depicting a loving family. Those images

with embedded sexual connotations can lead to discussion of what it was like at

puberty to experience sexual changes in the body and their psychosocial implications.

Similarly other images may be used to explore the later phases of adulthood and

eventual aging. Finally, Image A 30 may be useful for focusing more directly on the

subject of the end phases of life and human mortality. It is only through coming to grips

with the overall life cycle that true maturity is achieved. The SIS viewing experience can

facilitate this maturing process.

Body Imagery and Illness

The SIS-II images are stimulus material in the form of semi-ambiguous inkblots which

involve body and organ imagery. Unlike the Rorschach procedure, the designs are not

symmetrical. They are a bridge between fully ambiguous images and human figure

pictures (e.g. TAT cards), or drawings by clients.

Human figure drawings have been used to evaluate the subjective experiencing of

illness. Tait and Asher (1955) described their study of body imagery in a variety of

conditions in their article “Inside the Body Test.” The procedure involves giving the

subjects an outline of the human body, then having them draw and label their perception

of their illness.

Ingred Wickelgren (1989) reported how migraine patients perceived their headaches

in art. Ninai T. Matthew of the Houston Headache clinic has observed that paintings and

drawings can portray suffering and physical symptoms with vividness lacking in verbal

descriptions. In Boston, Egileus L. H. Speirling and John R. Graham have collected an

art series in this subject area. They have observed that migraine patients have obtained

psychological benefit from realizing they are not alone in their suffering, and that their

subjective experiences are due to a bonafide medical condition. Upon seeing “headache

art”, several patients told Speirling: “This is exactly like my pain. I can’t believe it.”

Marcia Wilkinson, of the London Migraine Clinic, pioneered British headache art had

provided the first examples of the perceptual distortion, long observed in classical

migraines. She found that many paintings and drawings of headache by sufferers had

a pattern of zigzag lines representing visual abnormalities associated with migraines

(Cassell, 1980). If this theory is applicable to the Somatic Inkblot Series, then it is

presumed that subjects suffering from physical illnesses, psychosomatic illnesses and

conversion reactions will perceive much more anatomical structure in the inkblots. In

general, somatic inkblot images should elicit mostly healthy anatomical responses in

individuals who are in good health.

Theoretical Postulates

Somatic Imagery Theory

Somatic imagery theory proposes that everyone has a unique and highly personalized

system of attitudes, both conscious and unconscious, that is projected onto the body

concept as a spacial entity. These interact with feedback sources and internal sensations.

Relatively discrete mental representations exist for particular somatic regions, which

constantly compete for full registration in consciousness. Somatic awareness transiently

increases in states of hunger, physical exertion, emotional arousal and sexual

excitement. Subsequently, the mental representations in the body fade into the

background of consciousness.

Alterations in body perception also occur in physical illness. In the diseased body,

pathophysiologic processes give rise to percepts from the diseased area, which directly

or indirectly, enter into awareness. The patient’s sensitivity to these depends partially

on the pre-existing body concept. Sensations that arise from regions of high priority in

the body gestalt are more likely to register than those from more perceptually silent

areas. If the sensations are subjectively considered aberrant, the individual must then

evaluate the significance of the sensations. At this stage, the patient makes a kind of lay

“diagnosis.” Intense pain or gross changes in body function are readily distinguished from normal body processes. However, other alterations such as early stages of disease formation pose problems for subjective interpretation. The cognitive appraisal of the altered body state is influenced by factors such as age, sex, socioeconomic status and past medical and family history of disease experience. There may be a strong motive, conscious or unconscious, to adopt a sick role to obtain disability compensation. There may also be a stress-induced wish to regress to an infantile, dependent position, and be taken care of by paternal figures such as a spouse, grown children, physicians, nurses or nursing home staff. Interaction between these multiple determinants will influence whether or not an individual decides to consult a physician to report subjective experiences. “Symptoms”

reported in the early stages of an initial visit represent verbal communication, which

contains spacial reference to specific organ images within the body. The information

content reflects altered anatomical awareness associated with the patient’s belief that

the given region has impaired function. The physician formulates a series of diagnostic

hypotheses based on “presenting symptoms”, on the nature of the underlying disease

processes. Then he conducts a formal medical interview, with questions designed to

uncover the pathological significance of somatic symptom clues. In most instances, an

insightful physician will be in a relatively strong position to establish a working diagnosis

upon completion of the history.

In this situation, there is no strong need for additional aids in diagnostic interviewing,

such as projective test techniques. There are, however, some cases when the diagnosis

is not clear. Patients may present symptoms, which do not fit into recognizable disease

patterns, or there may be major obstacles in communication with the individual. Some

patients minimize or deny physical illnesses while others exaggerate them.

16 Conceptualization of SIS

Clinical experience, upon which the SIS procedure builds, indicates that persons

suffering from physical illness, psychosomatic illness or conversion reaction will perceive

abnormal anatomical structure in the semi-ambiguous SIS images. There may be

sensitization with anatomy (increase in number of anatomical responses) or repression

with avoidance of somatic content.

When someone projects onto an image the response “sick stomach,” it may indicate a

concern or focus on that organ in one-self or another person. At times, it may signify a

deeper symbolization involving the stomach. This is consistent with Hermann

Rorschach’s suggestion that certain anatomical responses may be a projection of

kinesthetic sensations in the musculature. There are a variety of techniques, which can

be used to bring psychological conflicts to the surface. One example is dream analysis.

Another involves inkblot interpretation through content analysis of Rorschach responses

(Schafer, 1954, 1960). Other approaches involve artwork or sandtray analysis with

children.

Although “normal” perceptions reflect good reality contact, an individual’s perception

is never 100% congruent with objective reality, or conceptually subjective meanings.

Both the memory of visualization of the real world and dreams are contaminated by

personal, cognitive and affective percepts. Such internalized imagery may often elude

both traditional structured interviews and standardized psychological tests. The SIS

moves into these hard-to-tap areas through the use of video and computer electronic

techniques. These provide a window for examining inter-personal and psychic space,

in a way not previously possible.

By assessing an individual’s responses, and his/her associations with them, much can

be learned about the person’s innermost thoughts and feelings. What he sees in

ambiguous and semi-ambiguous images reveals his self-perception. In fact, it is

suggested that this new technology maybe applied by investigators of inner psychic

space in the 21st century, leading to the creation of new theory. At its present stage of

development, the SIS helps professionals to hear and empathize more sensitively with

the suffering individual’s “inner cry.” With previous approaches, the “inner cry” was

often hidden from others because of defensive mental mechanisms, which protect the

individual’s conscious awareness from discomfort. Many existing techniques employed

today are highly time consuming, not particularly cost-effective, and perhaps most

important of all, they do not readily provide a transparent window into the inner world.

Theory of Body Symbolism

Interest in the symbolic significance of the human body can be traced back to the very

dawn of civilization (Wentinck, 1972). Indeed, ancient wall paintings and stone carvings

evidence preoccupation with this subject. These distinguish Homo Sapiens from less

symbolically able species. Throughout history, pictorial representations of the body

have been a central theme of artistic expression of humanity’s search for identity.

Philosophically, such representations are an attempt to integrate mental and physical

phenomenon rather than to isolate or reduce them, as in Cartesian mind-body dualism.

When someone projects onto an inkblot the response “sick stomach”, it may indicate a

concern or focus on that organ in one-self or another person. It also might indicate

some association or deeper symbolization involving the stomach. An organic or

functional disorder in that organ system is consistent with Rorschach’s view that certain

anatomy responses may be a projection of kinesthetic sensation in the musculature

(Rorschach, 1951). Freud, and later Alexander and French, described how

gastrointestinal dysfunction or distress can be a manifestation of underlying

psychological conflict which is below conscious awareness.

Projective techniques geared specifically to body imagery and organ function assesses

both organic and functional disorders, real or imagined. Roy Schafer, a psychoanalyst,

advocated a content analysis approach (Schafer 1954, 1960). More recently, content

analysis has been reviewed in Aronow and Reznikoff’s book “Rorschach Content

Interpretation” (1973).

Qualitative content analysis assesses the individual’s imaginable mode of information

processing. It taps the same inner perceptual field as dream imagery. This occurs on a

continuum from pictorial recall to pictorial metaphor. Pictorial recall is visualized objective

reality, rational and realistic. Pictorial metaphor is a complex concept, which is highly

individualized, consisting of subjective associations of past experiences, interpretation

of present realities and future expectations along with their meaning. While “normal”

perception matches reality, it is never 100% congruent with objective fact. An example

is the relative unreliability of some eyewitness accounts. Memory and dreams are

contaminated by personal cognitive and affective percepts. These dynamics often

elude both structured interview and a battery of standardized psychological tests. They

are more readily understood through extensive symbolic analysis.

The Cry for Help

Clinicians worldwide have heard the cry for help in a variety of ways. These ranges

from abused children who escape stress through dissociative disorders to victims of

catastrophe or war, who suffer from post-traumatic stress disorders. Other manifestations

include ongoing frustrations in their life situations and in affective disorders or abnormal

behavior.

Some cry for help through their bodies, with Somatoform disorders. All these are

diagnosable by DSM or ICD criteria through use of definition and symptom checklists.

Underlying conflicts can also be manifested in subtle, more complex, and less dramatic

ways. Physical symptoms, such as functional disorders, hypersensitivity of an organ

system, or pain all in themselves may represent a form of a cry for help. There are daily

examples of this somatopsychic interaction in such expressions as “it’s a real pain in

the neck” (or elsewhere), “my heart was pounding” (broken, bleeding, or heavy), “what

a headache”, “he’s a hothead”, etc.

For physicians, therapists and researchers, the body, its organ systems and its perceived

functions are “doorways to the mind.” By observing and assessing how people perceive

or misperceive body and organ function, much can be learned about their innermost

thoughts and feelings. What they see in ambiguous and semi-ambiguous inkblots

shows how they see themselves, the quality of their life and lifestyle, their adjustment

to conflict, their coping skills and their view of the reality of life.

The Somatic Inkblot Series can help therapists more sensitively “hear” a suffering

individual’s cry for help, the “inner cry” that is not only hidden from others, but often

hidden from one’s own conscious awareness as well. This is the “magic”; the unique

and distinguishing feature of projective testing.

While the SIS uses somatic inkblots that involve body and organ imagery, a variety of

personal problems and mental disorders have been identified by them also. As stated

above, everyday conversations are replete with examples of the mind-body connection,

such as “broken heart” for depression or grief; “stuck in my craw”, “eating at my gut”,

“pain in the neck,” or “what a headache” are used for anger or frustration; “butterflies in my stomach” or “scared shitless” are used for fear or panic, to name just a few. Since projective tests are not based on verbal communication, they more effectively penetrate a person’s “outer shell” of defenses and surface behaviors. Unlike personality and intelligence tests, projective tests do not require reading questions or manuals, so they more directly access mental processes. They use the language of dreams, visual imagery and symbolic thought, the most basic forms of thinking and expression. Projective tests speak the language of repression and bring whatever is buried in the mind closer to consciousness, so it is accessible for processing. By developing a practiced eye and ear for this imagery, therapists can more directly share the perceptual world of their patients with less interference, and fewer variables than in structured interviews or so-called “paper and pencil tests.” If, as the saying goes, “a picture is worth a thousand words,” inkblots are picture recognition tests, and therefore are potentially more powerful than verbal interviews and tests. Therapists willing to more directly know and experience the patient’s psychic pain will be rewarded with clearer understanding of the psycho-dynamics involved, and therefore be able to provide more effective therapy. 18 Conceptualization of SIS