SIS Journal of Projective Psychology & Mental Health

JOURNAL OF PROJECTIVE PSYCHOLOGY & MENTAL HEALTH The Official Publication of the Somatic Inkblot Society Volume 10 Number 1 January, 2003 SIS ISSN 0971 - 6610 Vol. 10, No. 1, Pgs. 1-164 SIS JOURNAL OF PROJECTIVE PSYCHOLOGY & MENTAL HEALTH 2003

SIS JOURNAL OF PROJECTIVE PSYCHOLOGY AND MENTAL HEALTH is published twice a year (January, July) by the SOMATIC INKBLOT SOCIETY and is devoted to the advancement of research in the areas of projective psychology, personality assessment, psychotherapy and mental health. The journal is broadly concerned with the development of inkblot tests and personality assessment in clinical, counseling, cross-cultural, organizational and health psychology settings. It aims to reach clinical psychologists, psychotherapists, psychiatrists, social workers, medical professionals and professional managers interested in the understanding and modification of human behaviour. The journal includes (a) research articles (b) book reviews (c) brief reports (d) news about conferences etc. and letters to the editor. MANUSCRIPTS PREPARATION: Manuscripts should be typewritten (doublespaced throughout) submitted in duplicate to B.L. Dubey, Ph.D. Editor in Chief,SIS Journal, Post Box 1107, Sector-15 Post Office, Chandigarh 160015 (India). E-mail:sisdubey@rediffmail.com. Manuscript can also be submitted to Wilfred A. Cassell. M.D., Editor, 4501 East, 104th Avenue, Anchorage, AK-99516 (USA). E-mail: drcassell@gci.net. The Editors reserve the right to refuse manuscript submitted and to make minor additions/ deletions. Authors should prepare their manuscripts according to the Journal of Personality Assessment SUBSCRIPTION: The journal is free to members of the Society, Annual membership fees are US $40 for foreign members and Rs. 250, for Indian members, Institutional subscriptions are US $100 for Foreign institutions and Rs. 500 for Indian institutions. Life membership is US $300. for foreign members and Rs. 2000/- for Indian members. Non-members may subscribe for $30 or Rs. 150 per issue. Cheques should be made payable to ‘SOMATIC INKBLOT SOCIETY’ Chandigarh and should reach Dr. B.L. Dubey, Editor in Chief, (Address given above). Please add $5./Rs.60/- if you are sending subscription through cheque. CHANGE OF ADDRESS. Society / journal members should inform Mrs Padma Dwivedi, Treasurer, Somatic Inkblot Center, Post Box 1107, Sector-15 Post Office, Chandigarh-160015 (India), Tel/Fax 91-172-710986, email: sisdubey@hotmail.com OR sisdubey@rediffmail.com and Foreign Members should inform Mr.Anand Dubey Joint Editor, 4240 Edinburgh Drive, Anchorage, AK - 99515 (U.S.A.) Tel:(907) 344-0350, Email: adubey@rediffmail.com of any change of mailing address. Copyright @ 1994. SOMATIC INKBLOT CENTER, India/Anchorage U.S.A. Website: http://www.somaticinkblots.com

STATEMENT SHOWING OWNERSHIP AND OTHER PARTICULARS ABOUT SIS JOURNAL OF PROJECTIVE PSYCHOLOGY AND MENTAL HEALTH PLACE OF PUBLICATION : T-2/15, Sector-25 Chandigarh - 160014 PERIODICITY OF PUBLICATION : Half Yearly EDITOR'S PRINTER'S Name : Dr. B.L. Dubey PUBLISHER'S NATIONALITY : Indian ADDRESS : T-2/15, Sector 25, Chandigarh - 160015 OWNER : SOMATIC INKBLOT SOCIETY I, Dr. B.L. Dubey, hereby declare that the particulars given above are true to the best of my knowledge and belief. Sd/ Dr. B.L. Dubey, Editor-in-Chief SIS Journal of Projective Psychology and Mental Health Printed and Published by Dr. B.L. Dubey on behalf of Somatic Inkblot Society from T-2/15, Sector 25, Chandigarh - 160014 & Printed at Juneja Trading Agencies Pvt. Ltd. Printing Press, SCO 131-132, Sector 17-C, Chandigarh. Tel. : 702675, 704715. Editor : Dr. B.L. Dubey

SIS JOURNAL OF PROJECTIVE PSYCHOLOGY & MENTAL HEALTH (OFFICIAL JOURNAL OF SOMATIC INKBLOT SOCIETY) EDITOR-IN-CHIEF : B.L. Dubey, Ph.D., Director SIS Center India, Post Box 1107, Sector 15 Post Office, Chandigarh-160 015 [Res. : T2/15, Sector 25, Chandigarh-160014 (India)] Tel/fax : 91-172-710986, Tel.: 91-172-710985, E-Mail: sisdubey@hotmail.com OR sisdubey@rediffmail.com EDITORS : Anil Agrawal, BE, MBA, Chief Executive Officer, Telephone Cables Ltd., 68-70, Sector 17-C, Chandigarh-160017 Tel. : 91-172-704368 E-mail : aagarwal@teclindia.com : Wilfred A. Cassell, MD, Director, SIS Center, 4501E, 104th Ave. Anchorage, AK 99516 (USA). E-Mail: drcassell@gci.net : Padma Dwivedi, M.A., Social Worker, Dept. of Cardiology, Post Graduate Medical Institute, Chandigarh-160 012 Tel/fax : 91-172-710986, Tel.: 91-172-710985, : D. Saldanha, MD, Psychiatrist, Dept. of Psychriatry, Military Hospital, Meerut -250001India, E-mail : d_saldanha@yahoo.com JOINT EDITORS : S. Chaudhury, MD, Ph.D., Consultant Psychiatrist, Dept. of Psychiatry, Amred Forces Medical College, Pune-411040 Tel. : 91-20-6835348 (H) E-mail : suprakashch@vsnl.net : Anand Dubey, MBA, SIS Center, 4240 Edinburgh Drive, Anchorage, AK 99515 (USA) E-Mail: adubey@hotmail.com : Mridula Mishra, Ph.D., Lecturer, Bihar Yoga Bharati, Munger-811201 (India) Tel. : 91-6344-22430 : M.P. Singh, Ph.D, Lecturer, 1329, Sector 70, Mohali-Chandigarh Tel. : 91-172-223658 (H) E-mail : dr_mpsingh@rediffmail.com Marisa Porecca, Ph.D., Italy S. Ramachandra, Ph.D., India C.S. Rao, Ph.D., India Barry A. Ritzler, Ph.D., U.S.A. Ferro Roberto, Ph.D., Italy Ann M. O'Roark, Ph.D., U.S.A. M. Sahay, Ph.D., India Abhayman Sidhu, MBA, India Amool R. Singh, Ph.D., India David Sperbeck, Ph.D., USA Ailo Uhinki Ps.D., Finland De-Cicero E. Vaz, Ph.D., Brazil Yasho V. Verma, Ph.D., India Abstracted in “APA’s Psychological Abstract” Regd. No. 71632/99, RNI Delhi Phillip W. Baker, Ed.D., U.S.A Mahesh Bhargava, Ph.D., India D.K. Bhatt, B.E., India Alfred Collins, Ph.D., U.S.A. Carina Coulacoglou, Ph.D., Greece C.B. Dwivedi, Ph.D, India K.V. Kaliappan, Ph.D., India Anatoly B. Khromov, Russia Nalini Mishra, Ph.D., India Vipul Mittra, IAS, India Anjana Mukhopadhyay, Ph.D. India Rakesh Pandey, Ph.D., India Paul E. Panek, Ph.D., U.S.A. EDITORIAL CONSULTANTS

SIS Journal of Projective Psychology & Mental Health Volume 10, Number 1, January 2003 Contents Page Nos. Editorial i-ii Chapter 1: Introduction What is SIS ? Chapter 2 : Historical Development of Inkblot Technique History of Inkblot Procedure Beginning of Inkblot Procedure Existing Inkblot Tests Chapter 3 : Conceptualization of The SIS Procedure Need For Development Somatic Inkblot Series-I : 20 Cards Somatic Inkblot Series-II : Booklet-62 Images Somatic Inkblot Series-II : Video Body Imagery and Illness Theoretical Postulates Somatic Imagery Theory Theory of Body Symbolism The Cry For Help Chapter 4 : Psychometric Properties Reliability and Validity Response Consistency Split-Half Reliability Inter-Scorer Reliability Validity Normative Data Chapter 5: Administration Procedure and Instructions Video Procedure Examination Instructions SIS-II Booklet Procedure Benefits Chapter 6: Scoring and Charting Definitions of Scoring Indices Total Number of Responses Human Responses Animal Responses Anatomical Responses Sex Responses

Movement Responses Most Typical Responses Typical Responses Atypical Responses Typical and Atypical Responses (SIS-II A) Typical and Atypical Responses (SIS-II B) Rejection of Images Pathological Scales Pathological Anatomy Scale (PAS) Depression Scale (D) Hostility and Aggression Scale (HAS) Paranoia Scale (P) Charting of Responses - an Illustration Clinical Considerations Rejection of Images Chapter 7 : Interpretation and Application of SIS Responses Medical, Psychological and Spiritual Application of SIS Inkblots Guidelines for Interpretation of SIS Responses Rejection of SIS Images SIS-II/Video Death Scene Hallucinations and Delayed Grief Reactions Dream Programming Releasing Repressed Satanic Memories Stimulating Christian Imagery Case 1 - A Case of Headache and Stammering Case 2 - Police Case “Assault on Policeman.” Case 3 - Police Case “Witnessing an Accident.” Case 4 - SIS in a Case of Alopecia Areata. Case 5 - Bereavement and Hypnosis. Case 6 - SIS in a Case of Somatic Disorder Case 7 - Therapeutic Dream Stimulation Case 8 - The SIS and Hypno-Therapy in a Case of Marital Problems Case 9 - SIS in a Case of Examination Anxiety Case 10- SIS in Sexually Assaulted Female Case 11- The Use of the SIS and Rorschach in Releasing Somatised Grief Bibliography Author Index Subject Index

Preface In the SIS-II Video and computer version a series of flowers are initially presented to induce relaxation and an altered state of consciousness. This alters the registration and conscious awareness of current sensations and memories. Intermediate and long term memories, especially those derived from unresolved traumatic events, may now compete far more strongly in flooding projective awareness. When this takes place long forgotten painful events may be visualized in the video and/or computer screen. Through this time machine reversing technology, the viewer is afforded the psycho physiologic, emotional, and cognitive opportunity to process the activated imagery, while viewing flowers and nature scenes, reconditioning the nervous system in a therapeutic fashion. This complex series of mind body events was first discovered clinically in 1992 after a policeman described his experience in viewing the SIS-II Video. He had been admitted to a psychiatric hospital for treatment of Major depression. He had previously worked as a law enforcement officer in a remote Alaskan native village with an extensive history of alcohol related accidents. After he made a series of arrests of drunken drivers who had political influence with the mayor, his employment had been abruptly terminated. It was apparent that this immediate stressor had triggered his depressive illness. When he viewed the SIS-II Video, new contributing stress imagery was found to be compounding his overall mental disturbance. In viewing image A2, he relived an accident in which an intoxicated driver had injured a family fifteen years earlier. It was relatively easy to understand how such past occupational memories and post- traumatic dreams could inflame his hatred for drunken drivers. What was even more surprising and insightful into the therapeutic potential of the SIS technology was his comment that the viewing procedure had somehow, “helped him.” This had been achieved, remarkably enough, prior to any professional debriefing or psychotherapeutic intervention. In developing a conceptual model to understand this man’s viewing experience, it appeared that even long forgotten traumatic dreams could be reactivated in memory storage by SIS visual stimulation. From this point onwards in evaluating traumatized individuals, a close parallel was regularly observed between the individual’s dreams and SIS responses. It became apparent that the significance of SIS responses rated by the subject as “ most disliked, “was quite comparable to analyzing the direct and symbolic content of dreams This can be easily illustrated by considering a case treated in my hospital practice earlier this week. A fifteen-year-old Alaskan native girl had been admitted after an unsuccessful suicide episode. She was from a remote village and had been reared in an alcoholic dysfunctional family. At the time of viewing, her older brother was in an emergency ward, having had drug-induced convulsions following a serious overdose of drugs. She was also grieving the loss of several family members who had died in alcohol related motor vehicle accidents. Death themes constantly entered her dreams, disrupting her sleep and tormenting her. In viewing the computer screen, she rated A2 of SIS-II as the one she most disliked: “I see a cross formed with blood…I have a problem with blood.” When asked what blood brought to mind, she added, “It’s just like the dream…a death dream that would just keep returning…I was taking a shower and where the water comes out, all of a sudden blood comes out and everywhere there is blood…Every time I have that dream someone dies.” i

Relative to her personal death anxiety, she also reported the following dream: “I am walking into our church and everybody is crying…and then it turns out to be a funeral…and I try to talk to people but nobody sees me and nobody is listening…I walk up to the coffin and I see myself lying there…and I try to tell them that I didn’t die…I’m not dead, but nobody listens and I feel almost invisible.” This illustrates how the SIS more readily allows the interviewer to be able to listen to the suffering person’s inner cry and death fears. The SIS manual that is published in this journal provides detailed information about such cases. Many of these involve individuals who have suffered from severe psychological trauma. Those who chose to learn about this need to be aware of the occupational risk of being exposed to material capable of inducing secondary or empathetic PTSD. In any case, the cases serve to illustrate how content analyze methodology in association with symbolic interpretation can enrich traditional diagnostic treatment approaches in clinical settings. The manual also includes a series of statistical scoring systems with normative data to supplement the insights derived from the phenomenological case history method. The latter norms have also been particularly helpful in screening subjects in industrial type settings. All of this and much more are outlined in the manual. In addition certain illustrations examine somatic-psychological-spiritual dimensions beyond the limits of traditional scientific inquiry. For example, continuing the “time machine” analogy, the SIS can explore the ultimate psychic trip during which suicidal impulses push the individual to death. The study of this inner struggle, between the forces of life and those for self-destruction, has many implications for health. Those who study the manual and learn this electronic based sound and visual technology have an opportunity to push the frontiers of human knowledge beyond that which can be explored with existing projective techniques. Participating in the SIS society promises to enrich ones life and give much personal satisfaction. Like the Native girl’s death dream, imaging one’s body at death can provide a motivating psychic force for redirecting our life’s work. It can challenge us to rise above instinctual and materialistic based drives in order to optimally redirect energy to the higher human goals. Prospective members are warmly invited to complete the following philosophical visualization exercise to facilitate spiritually connecting to members of our society. If you elect to participate, conjure up in consciousness a mental representation of Image B 22. Now imagine that the figure represents your own body at death with your soul leaving. Next picture in your memory situations or dreams, in which your soul interacted with a deceased loved one or mentor that had a positive effect on your personal, emotional and cognitive development. Now incorporate these images into your living body image and spiritually connect with active members of our international society. You are now part of us. Welcome! Wilfred A.Cassell, M.D.,FAPA,APC President Somatic Inkblot Society Bankey L. Dubey, Ph. D. Editor in Chief SIS Journal ii Cassell

Foreword “Dr. Cassell takes full advantage of new video technology in developing his interesting inkblot technique, the Somatic Inkblot Series. Considerable effort and artistic talent has gone into the development of this method, which clearly deserves further research. In the hands of an experienced clinician, particularly after receiving competent training and supervision from Dr. Cassell or one of his colleagues, the Somatic Inkblot Series is a most welcome new projective technique for the assessment of personality and psychopathology. Unlike many other methods, it is particularly appealing when used by the clinician and subject as an interactive, interpretive mode as a part of the total diagnostic and treatment process. The dynamic nature of the stimulus, when presented by video in full color reaches well beyond the limitations of traditional projective techniques.” Wayne Holtzman, Ph.D Hogg Foundation for Mental Health The University of Texas, P.O.Box:7998, Austin, Texas 78713-7998 i

iii Acknowledgement This Manual is dedicated to Mary A. Cassell, whose support, patience and love have made this whole project possible. We are also very thankful and grateful to the many patients/clients who shared their pain and insights with us and all those involved in the work: to James Chapman, Seymour Fisher, Marc Hollender, Wayne Holtzman, Walter Klopfer, Alexander Levitan, Frank Machovec and Teddy Weckowicz whose interest, comments, and encouragement helped the concepts flow. To Elizabeth Bellamy, Debra Brady, Patrick Brady, Pat Davidson, Padma Dwivedi, Anand Dubey, Asheem Dubey, Edith Eger, Raymond Fedje, Don Fields, Margaret Fischer, Jay Fisk, Kristen Gillen, William Kellis, Bruce Livingstone, Paola Nicolini, Anatoly Khromov, Mridula Mishra, Kumiko Murayama, Jim Murphy, Robert Morgan, Ann M. O’Roark, Marianne Robinson, Gilbert Roth, George Savage, David Sperbeck, and all the students, clinicians and researchers who have long been involved in this labor of love. To Larry and Sharon Moore, Larry Brummer, Sue Close, and the technical staff at TCS Video Production Center. A special thanks to Anil Agrawal, N.L. Dosajh, C.B. Dwivedi, K.V. Kaliappan, Nalini Mishra, Gopa Mitra, Anjana Mukhopadhyay, Rakesh Pandey, D. Pershad, S. Ramachandra, S.P.Rathee, M. Sahay, D. Saldanha, Amool R. Singh, M.P.Singh and many excellent professionals in India for help. Wilfred A. Cassell & Bankey L. Dubey

List of Tables Tables Page No. Table 1 : Agreement of Responses on Repeat Administration Table 2 : Test Re-test Reliability of the Contents of SIS-II Table 3 : Means and Correlation between Series A and Series B Table 4 : Distribution of Atypical Responses Table 5 : Mean Number of Most Typical Responses Table 6 : Comparison of Healthy Controls With Clinical Groups on Different Categories of Responses on SIS-II Video Table 7 : Mean Scores and SD on Nine Indices of the SIS-II for Normal and Pathological Groups Table 8 : Intergroup Comparisons for Different Scoring Categories of the SIS-II Table 9 : Multiple Discriminant Function Analysis in Terms of U-Statistic and Corresponding F-Ratios for Identifying the Best Predictors of SIS-II Table 10 : Percentile Norms Based on the Responses of Normal Control for Nine Scoring Indices of the SIS-II Table 11 : Comparison of SIS Indices for Alcohol Dependent Group Table 12 : Comparison of SIS Indices for Drug Dependent Group Table 13 : Pathological Indices in Normal and Clinical Groups Table 14 : SIS Images Assessing Different Areas Table 15 : Comparison of Responses on SIS-II and SIS Video in Healthy Normal 33 Table 16 : Comparison of Responses on Series A and Series B of SIS Video Table 17 : Diagnostic Indicators of SIS-II/ Video Table 18 : Successful SIS Indices Table 19 : SIS Video Responses of Executives in India Table 20 : Comparison of Adults with Adolescents Table 21 : Comparison of Series A and Series B in Adolescents Table 22 :Compatibility of SIS-II and Rorschach Indices in Normal and Psychiatric Groups Table 23 : Kendall’s Coefficients of Concordance between the Nine Scoring Indices of SIS and Rorschach Table 24 : Comparision of Rorschach Responses on 1st, 2nd, 3rd and 4th Testing. Table 25 : Comparision of a Few Significant SIS-I Responses on 1st, 2nd, 3rd and 4th Testing. Table 26 : Comparision of a Few Significant SIS-Video Responses on 1st, 2nd, 3rd and 4th Testing. iv

About the Authors Dr.Wilfred A.Cassell is a licensed physician and is certified by the American Board of Psychiatry. He is also a Fellow of the American Psychiatric Association, the American Psychological Society and the Somatic Inkblot Society and a member of the Alaska State Medical and the American Medical Associations, Society for Personality Assessment, International Society for Traumatic Stress Studies, International council of Applied Psychology and International Council of Psychologists. Presently he is the President of Somatic Inkblot Society. He also has an extensive outpatient practice and works with children, adolescents and adults. He has written more than a hundred articles in professional journals and the book “Body Symbolism and the Somatic Inkblot Series.” He is a frequent speaker at state, national and international conferences. He lives in Anchorage, Alaska, where he enjoys the outdoors and the unspoiled beauty of the “last frontier.” Dr. Bankey Lal Dubey has done his Ph.D. in 1978 on psychiatric population employing the Rorschach Inkblot Test and established diagnostic indices for Schizophrenics and Neurotics. He has also done post-master program in clinical psychology from National Institute of Mental Health & Neuro Sciences, Bangalore in 1968 and has undergone training in Hypnosis in USA in 1985 and 1992. Dr. Dubey has published more than 150 research papers and two books, one on “Pragmatic View of Rorschach Inkblot Technique”. He is a fellow of Somatic Inkblot Society and a member of Society for Personality Assessment and International Rorschach Society. He started his career in T. N. Medical College, Bombay in 1969 and served Indian Army (Command Hospital) for 8 years and shifted in 1980 to Panjab University Chandigarh where he is working as Professor. He was associated with Montari Group of Industries (1992-1995) where SIS test was used during selection and promotion interview. He is also associated with Post-Graduate Institute of Medical Education & Research Chandigarh as Guest Faculty. Presently he is Editor in Chief of SIS Journal of Projective Psychology and Mental Health. He has travelled widely and conducted workshops on the applications of Somatic Inkblot Series in various countries and lives in Chandigarh India.

Chapter 1 Introduction

Introduction The Somatic Inkblot Series (SIS) is a structured, projective, diagnostic procedure and is an adjunct to psychotherapy and counseling. The SIS is structured by a sequential presentation of intentionally designed and field-tested inkblot-like images. These images demonstrate typical and atypical response potentials. The SIS procedure is projective because it is based on spontaneous, individually generated responses to semi-ambiguous figures, which elicit intrapsychic associations specific to the person presented with them. The SIS is a diagnostic procedure as a consequence of the interaction of structure and stimuli. These stimuli evoke symbolism and meanings unique to the responding individual. These can be differentiated from typical and atypical peer norms, and can be analyzed according to internationally recognized diagnostic criteria. The procedure is an adjunct to therapy because responses can be further explored to create a more effective treatment plan, and can be re-addressed in later discussions, providing opportunities to elicit deeply defended material. During the administration of the SIS procedure, clients, patients and students may abreact emotional conflict raised to consciousness by the images, which can be a therapeutic experience in itself. What is the Somatic Inkblot Series ? The Somatic Inkblot Series (SIS) was originally conceived in 1959. After years of research and field-testing on SIS-I, the SIS-II (62 image Booklet Form) was developed in 1980. Encouraged by the tremendous success of the booklet form, the SIS-Video (video version of 62 images Booklet Form) was launched in 1984. It provides diagnostic and therapeutic aid. The SIS-Video is a self-administered test consisting of five segments: 1. A series of beautiful flowers to reduce test anxiety. 2. An instructional section in which a “subject” illustrates how to give free associations to a video inkblot. 3. An induction period in which semi-hypnotic relaxation suggestions are given. 4. A test section in which 62 specifically-designed images having color, structured form and, at times, movement are presented. 5. A recovery portion in which a series of non-threatening nature scenes, combined with upbeat music, bring the viewer back to the time and space reality of the test situation. The viewer writes responses on an answer sheet. Most of what is included in the ambiguous structure relates to specific life situations and post-traumatic dream content that has been found to have clinical significance. Viewing the SIS has both diagnostic and therapeutic applications that are far reaching. Introduction 1

The SIS Video is highly innovative and, in a sense, a “time machine.” It takes the viewer away from present reality. If there is unresolved painful material in the past memory storage, through the magic of television, the projected responses will tend to be shaped by this material. This can emerge even though the viewer may have long forgotten the buried traumatic images and their associated affect. It facilitates the expression of feelings and earlier forgotten life events underlying many forms of mental illness and conversion pain. When the viewer rates those images which are the most threatening, the examiner gets a quick psychological overview of the subject. The technique enables the professional to more readily empathize. The administration of the SIS is designed to maximize the pulling power of inkblot projection. The subject is given an answer booklet. The first section includes a health questionnaire. The process of filling out the health questionnaire creates an immediate perceptual set to project images related to medical and psychiatric problems, for themselves or for loved ones. The space/time dimensions of the viewing situation are subtly altered by the video presentation of mesmerizing flowers. These are electronically transformed so the viewer experiences a magical feeling of traveling through a mental garden of beautiful flowers. This draws the subject away from the present reality, back in time, to episodes of previous illness or trauma. Following this sequence, a photograph of a beautiful mountain, followed by an artist’s rendition of the same scene, heightens the hypnotic effect. Next, an example of a person responding to a typical inkblot is cited to show the viewer how to fill out the answer booklet. After this presentation, audio suggestions to relax set the stage for slipping further back in time and re-experiencing images of illness or post-traumatic dreams. During the initial viewing, the subject is entirely alone just as in dreaming. This eliminates the inhibiting effect of another’s presence. By writing responses, rather than verbalizing them, just like in hypnotic writing, the subject may more readily access and release painful material. In addition to the cathartic, therapeutic response, the person may gain some insight and sense of mastery of the traumatic material by the act of drawing and labeling the images. Also, when the procedure is assigned repetitively over time, the experiencing of the healing flowers, in association with the threatening, anxiety-laden images may serve to desensitize the viewer. In many instances, there is a sufficient richness of material elicited by interviewing the subject concerning the “threatening” images, that little more needs to be delved into. In this sense, for the busy clinician or interviewer, the procedure readily serves as what has been referred to as a “quick and dirty” test. Occasionally, an insightful subject may, after having completed the procedure, or having experienced previously repressed post-traumatic dreams, open the interview with a statement about how helpful it was. This person may simply wish to elaborate on memories of past upsetting experiences such as an emotionally unresolved abortion, a miscarriage, past psychological, physical or sexual abuse, or the witnessing of an accident, etc. Given the power of the technique, it Introduction

is rarely necessary to review associations to the entire 62 images. However, the psychologist, who becomes sophisticated concerning content analysis and symbolic interpretation, may glean much additional information from an overall scrutiny of the responses. Applications of this procedure have proven to be far-reaching and international. The use of graphic images, rather than words, allows the SIS Video to cross both cultural and language boundaries. The number of uses in medical diagnosis, psychological assessment and psychotherapy is rapidly growing. It is anticipated that in the 21st century, all students of the healing arts and psychology, during their training will have the opportunity to be introduced to this technique. Currently, a complete data bank is being developed where individuals from various SIS Centers around the world may submit data and access information via modem or facsimile communication. This could truly be a comprehensive artificial intelligence system to be employed for good in a world beset by evil. Introduction 3

SOMATIC INKBLOT SOCIETY is publishing its Journal SIS JOURNAL OF PROJECTIVE PSYCHOLOGY AND MENTAL HEALTH a half yearly publication in January and July. It has 2 Awards of $250 employing the use of Inkblot Tests SIS & Rorschach. For details please contact : Wilfred A. Cassell, M.D., FAPA, APC, FSIS, Director, Somatic Inkblot Center, President, Somatic Inkblot Society and Editor, SIS Journal of Projective Psychology & Mental Health, 4501E, 104th Avenue, Anchorage, AK 99516 USA. E-Mail : drcassel@gci.net Web Site at http: //www.somaticinkblots.com OR B. L. Dubey, Ph.D., DPM, FSIS, Editor in Chief, SIS Jr. of Proj. Psy. & Mental Health, Director Somatic Inkblot Center India, P.O. Box 1107, Sector 15 Post Office, Chandgarh-160015 (India) Tele/Fax : 91-172-710986, Tel. : 91-172-710985 E-mail : sisdubey@rediffmail.com OR sisdubey@hotmail.com

Historical Development of Inkblot Technique History of Inkblot Procedures In many countries, performing psycho-diagnosis is a major role of the psychologist who works in a clinical setting. Among the psychological tests most frequently used, inkblot techniques are the most favored (Sundberg, 1961; Hinkle, Nelson and Miller, 1968; Sharma, Ojha and Vagrecha, 1975; Wade, Baker, Morton and Baker, 1978; Dubey, 1982). Published in 1921, the Rorschach psycho-diagnostic test occupied a major position in the inkblot technique until 1956 when Wayne Holtzman developed his technique, to overcome some of the limitations of the Rorschach. The needs of the busy clinicians and the increasing demands for psycho-diagnosis inspired Wilfred Cassell to develop a system of inkblot techniques. He uses modern video technology to make it usable as a self-administered technique. Before discussing the various limitations of existing inkblot techniques, it is worthwhile to trace the history of the use of inkblot procedures in psychological investigation. Beginning of Inkblot Procedure The history of the inkblot procedure is not easily traced. It is traceable only through Rorschach’s own writing, and through the writings of Emil Oberholzer, Walter Morgenthaler and George Roemer. Zubin, Eron and Schumer (1965) indicated that the concept of formless stimuli, used in inkblot techniques to stimulate the imagination, can be traced back to Leonardo Da Vinci and Botticelli in the fifteenth century. Exner (1969) wrote that it was important to note that in Europe during the latter half of the nineteenth century, and the early part of the twentieth century, there was much public interest in inkblots, not as a test but more as a game. It was very common for inkblots to be used in a popular parlor game called “Blotto”, where the challenge was to associate an image to a design. The design might well have been created right there, or taken from the many inkblots and similar designs appearing in contemporary books and magazines. “More formally, there was in Europe and the United States, considerable experimentation attempted with inkblots as tests of imagination, personality and intelligence. Krugman (1942) cites the evidence that as early as 1895, Binet and Henri suggested that inkblots could be used for studying various personality traits, especially visual imagination. Dearborn, while working at Harvard University, published an article in 1897 discussed the potentials of employing inkblot techniques in experimental psychology. As Tulchin mentions, in 1848 Dearborn published the results of applying an inkblot technique to a group of sixteen subjects, wherein he used twelve sets of inkblots, each having ten blots similar in nature. Tulchin also cites the pre- Rorschach work of Sharp, Kirkpatrick, Whipple, Pyle, Bartlette and Parsons, all of whom published material between 1900 and 1917 concerning inkblot methodology in the United States and England” (Exner, 1974). Historical Development 5

Baumgarten-Traumer (1942) mentioned that in 1910 in Moscow there appeared an atlas for experimental research on personality, published by a Russian psychologist named Theodere Rybakow who was a tutor at Moscow University. In the atlas, there was a test consisting of eight inkblots. All of them were asymmetrical. Rybakow indicated that her husband’s decision to work with inkblots was stimulated by the observations of Konard Gehring, a teacher. Gehring discovered while using inkblots displayed on very large sheets of paper at the front of the classroom, that certain children gave very similar responses to a variety of inkblots, even though the images were different in their form and color. Zubin and Eron (1966) described three periods in the history of inkblot use in projective testing. Artists who painted “indeterminate forms to simulate creative imagination” comprised the pre-experimental period in the nineteenth century. Binet introduced the “psychological experimental period” in 1895 with his assessment techniques, which measured imagination as an index of cognitive ability. Binet believed that a large number and variety of inkblot responses were a positive correlation to a “lively visual imagination” (Binet and Henry, 1895). Other inkblot researchers hypothesized that conscious awareness was slowed by ambiguous stimuli, thus making the perceptual process accessible for research purposes (Dearborn, 1897; Whipple, 1910). The third historical period began in 1911 with Herman Rorschach’s innovative research on “the interpretation of accidental forms” (1951). His interest in art forms and perception surfaced when he was a schoolboy. He was affectionately nicknamed “Klex” or “inkblots” by his peers (Cassell, 1980). Roemer (1967) wrote that Rorschach’s first purpose for developing an inkblot test was to investigate the subject’s reflex hallucination through viewing inkblots. Cassell (1965) initially used inkblots to study the subject’s body perceptions and somatic symptoms. Cassell (1980) extended his use of this technique to where the clinician could better hear the suffering individual’s “inner cry.” In summary, it can be said that the beginning of inkblot use may be traced back to the fifteenth century and that a sizable amount of work was done towards the end of the nineteenth century. Inkblot procedures have been used for studying imagination, thought processes, reflex hallucinations, intelligence and personality. Currently, they are being used to understand the subject’s psychopathology and to hear his/her “inner cry.” At present the work is going on at various international SIS Centers. Existing Inkblot Tests There are three major standardized tests based on inkblots. The pioneer amongst them was the Rorschach Inkblot Test published in 1921. Use of this test to explore the subject’s psychopathology and basic personality structure is well known. A research publication by Reynolds and Sundberg (1976) ranked the Rorschach test as number one. They based their findings on Buros Mental Measure Yearbook. A survey conducted on the members of The American Psychological Association Division-12, and The Indian Historical Development

Association of Clinical Psychologists showed concern from respondents about the limitations of the test (Wade et al 1978; Sharma, Ojha and Vagrecha, 1975; Dubey, 1982). Zubin (1965) has charged seven major failures as follows: 1. Failure to provide an objective system, free of arbitrary conventions, and showing high interscorer agreement. 2. Lack of satisfactory internal consistency, or test-retest reliability. 3. Failure to provide cogent evidence for clinical validity. 4. Failure of the individual Rorschach scoring categories to relate to diagnosis. 5. Lack of prognostic, or predictive validity with respect to the outcome of treatment, or later behavior. 6. Individual differences between groups of normal subjects. 7. Failure to find any significant relationships between Rorschach scores and intelligence, or creative ability. In 1953, Fiske and Baughman reported that practitioners feel that the variation in the total number of responses is too much to be able to interpret the ratio scores adequately. Also, the meaning of the indices changes depending upon the length of the protocol, because the relationship between Rorschach scores and the total number of responses is complex and curvilinear. Many workers compute percentage ratio in an effort to control the length of the protocol. Holtzman (1956) pointed out that such procedures were very unsatisfactory, not only because of the non-linear relationships between R and other Rorschach’s scores, but also because of the crude, unstable and metric qualities of most Rorschach variables. Holtzman et al (1956) pointed out that much of the controversy over the Rorschach arises from the failure to distinguish between the Rorschach as a projective technique in the hands of a skilled clinician, and the Rorschach as a psychometric device, that yields scores having relevance for personality assessment. The analysis of responses to inkblots has ranged all the way from one extreme to the other of the projective psychometric continuum. Wayne Holtzman developed an inkblot test to overcome some of the limitations of the Rorschach. The main limitation of the Rorschach, as experientially determined, was the problem of variation in the length of the protocol (Fiske and Baughman, 1953; Dubey et al, 1978, 1979, 1989). As Fiske and Baughman pointed out, the relationship between Rorschach scores and the total number of responses are complex and curvilinear. Consequently, the usual effect of R linear regression methods for removing the confounding effect of R will generally fail. Historical Development 7

Dubey, (1982), in a study of 300 subjects, found that most of the Rorschach indices are dependent upon the number of responses. When the groups of Normal, Neurotics, and Schizophrenics were divided, on the basis of number of responses, into high productivity and low productivity, many indices which were found to be significant lost their significance. It further strengthened the findings of Fiske and Baughman, and supported the intention of Holtzman. The advantage, which Holtzman introduced in his test, was to offer an alternate series of the inkblot stimuli test for reassessing the personality after some type of intervention. Holtzman provided 45 cards in each series. The subject is required to give one response per card. Holtzman categorically selected only 22 variables such as: reaction time, location, form definiteness, form appropriateness, color, shading, movement, pathogonomic verbalization, integration, human, animal, anatomy, anxiety, hostility, barrier, penetration, popular, etc. His test is said to measure almost the same aspects of personality that are measured by the Rorschach. Holtzman has clearly emphasized the psychometric approach. The Holtzman test has wide application and is popular. However, the research output is not as prolific as that of the Rorschach test. The Somatic Inkblot Series is a recent extension of the traditional inkblot projective techniques. The test was developed specifically to understand the manifestation of problems through somatization, and to hear the suffering individual’s “inner cry.” The test images are viewed on a television using a video cassette recorder (VCR). The subject’s responses are recorded on a separate response sheet. The procedure can be done while the patient waits for his/her turn at a clinic or a hospital. In some cases where the individual has good ego strength, the procedure can be completed at home. Historical Development

Conceptualization of SIS 9 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

Conceptualization of SIS 11 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

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

Conceptualization of SIS 13 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 innocent. Image B 28 depicts a mother holding a child. This can serve to stimulate

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

Conceptualization of SIS 15 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.

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 Conceptualization of SIS 17

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. Conceptualization of SIS

Psychometric Properties Reliability and Validity Reliability and validity are concepts, which are very useful and can be arrived at statistically for psychometrically oriented objective instruments. Any projective test, however, cannot give numerical values for all of its parameters, on a single scale, and projective tests are also considered to be more of a measure of state rather than traits. Therefore, any slight difference in the environment or self can make some change in the precept or responses. Because of these limitations, the reliability and validity of projective tests are in true sense, a little difficult to determine. Nevertheless, in terms of consistency of responses, some scientific evidence is possible over a period of time, with the assumption that the time interval will not be so long that it will influence the perception of individual. Intra and inter-scorer reliability may be considered more in terms of interpretation or the concepts verbalized onto the images presented to the individual. Table 1 Agreement of Responses on Repeat Administration of SIS-II on Psychosomatic Subjects (n=100) Image Number Total % of Subject Images giving same response A12, A30, A31, B5, B22, B29 100 % B4, B15, B21 90 % A7, A13, A20, B8, B9, B16 ,B25, B31 80 % A1, A4, A6, A10, A16, A23, A25, A28, B7, B12, B23, B27, B28 70 % A9, A17, A29, B6, B18, B24, B26, B30 60 % A5, A14, A18, A21, A24, B2, B11 B14, B20 50 % A8, A11, A15, A19, B13 40 % A22, B3, B10, B17 30 % A2, A3, A27, B12 20 % A26 10 % B1 10 % Response Consistency In psychometric terms, it is known as score consistency. Since, in the Somatic Inkblot Series, there are no scores in true sense, we are calling it response consistency. Unlike Psychometric Properties 19

Rorschach and similar to Holtzman, the length of the protocol does not vary considerably from one administration to another. It has been found from various sources that the agreement in total number of responses when the test is repeated after a short time was very high. The detailed response consistency was undertaken for SIS-II images on Indian subjects (Dubey and Cassell, 1991). The absolute response consistency was found to be above 70 percent for the images A1, A4, A6, A7, A10, A12, A13, A16, A20, A23, A25, A28, A30, and A31 and B4, B5, B7, B8, B9, B12, B15, B16, B21, B22, B23, B25, B27, B28, B29, B31 for the remaining images it was 60 percent and less as shown in Table-1. The correlation for the content categories over a period of four weeks, on repeat testing was found to be more than .69 as shown in Table - 2. Table 2 Test Re-test Reliability of the Contents of SIS-II (n=100) Content categories Correlation (Rho) Human responses 0.88 Animal responses 0.71 Anatomical responses 0.76 Most Typical responses 0.69 High correlation indicates consistency in the pattern of responses and supports the high reliability of the test. Split-half Reliability Split-half reliability requires splitting of the test into two equal halves. Inkblot images cannot be split into two equal halves because they are heterogeneous. The task of categorizing the test into two equal halves is theoretically not only difficult but impossible, provided that the test is projective in its true sense. Many researchers, however, have tried to establish split-half reliability of the Rorschach test, not in terms of material, rather in terms of responses elicited on the test (Vernon, 1933; Hertz, 1934). The split-half reliability of SIS-II and SIS-Video was established by splitting the test into two equal halves. These equal halves are the natural divisions of the test that consists of two series, A and B. Cassell, claims that the SIS is a structured projective test, where images are selected, by and large, to elicit anatomical response. Therefore, it can be assumed that it is possible that Cassell might have something in mind to develop two parallel forms. However, in view of rigorous field testing, he chose to combine both sets “A” and “B” into one single test. Psychometric Properties

Table 3 Means and Correlation between Series A and Series B (n=220) Set A Set B t r Total Responses M 36.22 32.16 6.22 0.89 SD 7.92 5.60 p=.01 Most Typical Responses M 6.49 6.21 1.92 0.51 SD 1.68 1.39 n. s. Human Responses M 8.49 8.27 0.71 0.61 SD 3.59 3.08 n. s. Animal Responses M 5.25 3.63 5.79 0.71 SD 3.28 2.56 p=.01 Anatomical Responses M 5.59 4.56 3.41 0.66 SD 3.53 2.75 p=.01 Sex Responses M 2.15 1.66 2.52 0.67 SD 2.06 2.06 p=.02 Movement Responses M 4.69 4.12 1.85 0.66 SD 3.62 2.84 n. s. Rejection of Images M 0.73 1.38 2.86 0.76 SD 1.70 2.90 p=.01 The test re-test reliability reported hereafter might be considered as parallel form reliability as well. It was tested on 220 subjects (100 normal, 41 schizophrenics, 39 neurotics and 40 American neurotics) considering both set A and set B. Both the tests SIS-II and SIS-Video are alternate forms. The means and correlation of the two sets for the Total number of responses, Human responses, Animal responses, Anatomical responses, Sex responses, Movement responses, Most Typical responses, and Rejection of images are presented in Table 3. All the correlation between sets A and B of the SIS images were found to be statistically, highly significant for the eight variables considered. The lowest correlation was .51 for the “Most Typical’ responses. The highest correlation was .89 for the length of responses between sets “A” and “B.” This suggests that sets A and B may be considered as independent series for quicker assessment of the patient by the busy clinician. The two series can be used independently whenever a repeat assessment is suggested, after a short interval. The length of the stimulus material may produce feelings of fatigue and monotony in the subjects. The analysis presented in Table 3 clearly suggests that the total number of Responses, the number of Animal responses, the number of Anatomical responses, Psychometric Properties 21

and the number of Sex responses were significantly more in set “A” than set “B.” It might be assumed that the motivation of the subject deteriorates in set B, because the nature of the stimulus was not much different in the two sets. The hypothesis that the number of responses will be significantly reduced in the second set and is not determined by set A or B, is being tested at different centers. The initial observations, however, confirm the correctness of the hypothesis. Inter-scorer Reliability Inter-scorer reliability for the indices reported above was determined. The same protocol was scored separately by a trained and experienced clinical psychologist, having experience with the SIS, and by a fresh psychologist who was provided with a set of definitions for the variables as reported in a subsequent chapter. It was discovered that there was no difference between their two independent scorings. It can be argued that it was not a scoring, but merely a counting of the responses under different categories (Total number of Responses: Human responses, Animal responses, Anatomical responses, Sex responses, Movement responses, Most Typical responses and Rejection of images). Validity The validity of a psychological test is an essential characteristic that must be demonstrated beyond any doubt. Its validity can be based on theoretical assumptions, clinical experiences and its utility in the field. The division of tests into objective and projective requires different standards for measuring validity. The projective tests, such as the SIS, cannot be tested for validity, like objective tests. The SIS is a method of observation and appraisal. With regards to a test that measures some aspects of personality, it is legitimate to ask, “Is it valid?”. However, in regard to a method of observation, the appropriate questions are: “Is it useful?”, “Is it productive?”, “Does it conform to some construct?”. The SIS is an objective procedure for observation; therefore validity in psychometric terms cannot be determined. The question then arises; can we still call it a valid procedure? The clinical interview and the diagnostic procedures are based on the information elicited from the patient and his observations. Has anyone doubted the validity of such clinical interviews and diagnostic procedures? If not, the validity of the projective test, the SIS in particular, cannot be doubted if its utility is adequately established. It is therefore necessary to demonstrate empirically the content and construct validity of the SIS. The other types of validity generally given in textbooks cannot be determined. The SIS is a test that elicits mostly somatic responses and is based on the theories of body perception of Schema (body orientation) and body symbolization. The content validity of the test can be demonstrated if the patient with somatic problems is found to Psychometric Properties

give more somatic responses. This was assessed in a study of pregnant women and non-pregnant controls. The pregnant women projected more responses of a pregnancy theme than non-pregnant women did (Cassell, 1990). In a number of studies, it has been demonstrated beyond a doubt that relationships exist between an individual’s physical disturbances and his/her projected anatomical responses (Cassell, 1969, 1971, 1972, 1977, 1980; Dubey and Cassell, 1993, and Green grass and Adamson, 1977). In a current study on a heart patient in India, the interim results suggested that his somatic preoccupation was not verbalized any more than compared with a healthy control. It was interpreted that his body disturbances were consciously denied (Goel et al, 1990). Table 4 Distribution of Atypical Responses Number of Percentage of Subjects in Significance Atypical Responses Normal Neurotics Schizo. Dis. (n = 100) (n = 39) (n = 41) 0 - 2 X2 = 2.03 3 & more p = .01 *These were the adult subjects studied in India. To have construct validity on the basis of existing literature on inkblot technique, it can be assumed that Most Typical responses and Atypical responses have to be different in broad psychiatric diagnostic categories compared to healthy controls. This hypothesis was tested on Neurotics, Schizophrenics, and healthy Normal subjects. The following tables clearly confirm that Atypical responses were significantly higher in Psychotics than Neurotics and Normals. Likewise, Most Typical responses were significantly higher in normal subjects compared to psychiatric patients. Table 5 Mean Number of Most Typical Responses Normal Indian Schizophrenic American Neurotics Disorder Neurotics Number (n=) Mean 13.68 11.41 11.54 13.35 SD 1.98 3.76 2.29 1.93 F = 12.67; df = 3/216; p= .01 A number of other categories of responses like Total number of responses, Human responses, Animal responses, Anatomical responses, Sex responses, Movement Psychometric Properties 23

responses, Most Typical responses, and Rejection of Images were also analyzed with the assumption that Neurotics and Schizophrenics should differ from Normal subjects because of their different psychopathology. To test this assumption, 220 subjects consisting of 100 Indian normals, 39 Indian neurotics, 41 Indian schizophrenics, and 40 American neurotics, were administered the SIS-Video and analyzed. It was found that the normal subjects differed significantly from clinical groups on all the variables except for the mean number of Sex responses (Table 6). Table 6 Comparison of Healthy Controls with Clinical Groups on Different Categories of Responses on SIS-II/Video Indian American Indices Normal Neurotics Schizophrenic Neurotics F Disorders (n=100) (n=39) (n=41) (n=40) Total Responses M 74.08 63.92 64.71 61.60 20.34 SD 12.40 9.85 6.88 6.16 p=.01 Movement M 9.60 5.15 7.66 10. 62 8. 46 Responses SD 5.30 6.04 3.82 6.45 p=.01 Human Responses M 14.66 17. 26 18.17 19. 77 10. 23 SD 5.46 5.69 5.13 4. 94 p=. 01 Animal Responses M 8.65 8.82 10. 56 7. 30 3.18 SD 4.69 4.72 6.10 3. 01 p=.05 Anatomical Responses M 9.18 9.15 11.12 12.08 3. 72 SD 4.24 4.88 7.95 4. 56 p=.05 Sex Responses M 4.12 3.15 3.59 3. 30 1.08 SD 2.58 3.61 5.67 2. 82 ns Rejection of Images M 0.82 3.49 2.12 1. 78 5. 33 SD 2.00 6.27 4.09 2. 31 p=.01 The above table clearly indicates that the healthy controls had significantly different patterns of responses than the clinical groups. However, amongst clinical groups, there were not many significant differences. This might be interpreted to mean that the SIS, as viewed by its mentor is more a therapeutic instrument. Its real utility lies in its content analysis, which helps in understanding the psychopathology of the patient. This understanding can help in the psychotherapeutic procedure. No projective test can provide a categorization of the thought processes of the individual, because it is based on the perception of the sufferer and the circumstances around him. There is no set pattern in different diagnostic categories. This provides strength to the content validity of the test (Dubey et al, 1992). Psychometric Properties

Table 7 Mean Scores and SD on Nine Indices of the SIS-II for Normal and Pathological Groups Score Indices Normal Neurotics Schizophrenics Anxiety Neurotic Paranoid Undiffer- Neurotics Depressives entiated (n = 50) (n = 25) (n = 25 ) (n = 25) (n = 25) Total M 64. 34 64. 28 63.16 61.68 61.76 responses SD 4. 21 5. 45 3.39 3.36 2.28 Human M 21. 86 20.80 20.88 19.96 17.88 responses SD 4. 34 4.77 3.47 5.66 4.24 Animal M 7. 80 11.12 10.44 10.12 11.36 responses SD 3. 23 4.46 4.13 4.93 5.17 Anatomical M 12.20 13.44 14.40 12.44 16.04 responses SD 3. 79 5.94 5.66 6.69 7.63 Sex M 1.12 1.16 1.28 2.08 1.44 responses SD 1.32 1.62 1.43 2.85 1.75 Human M 3.46 2.44 3.48 3.12 2.24 Movement SD 2.58 1.90 2.90 3.00 2.08 Animal M 1.14 1.32 1.20 1.44 0.72 Movement SD 1.23 1.22 1.20 2.37 0.87 Most M 16.30 14.56 14.72 11.20 10.84 Typical SD 1.32 0.85 1.00 1.30 1.32 Rejection M 0.58 1.56 1.44 2.56 2.28 of Images SD 1.40 1.24 1.36 2.53 2.16 Mishra & Dwivedi (1997) In another study conducted by Mishra and Dwivedi (1997) on a sample of 150 subjects (50 normal, 25 each of anxiety neurosis, neurotic depressive, paranoid schizophrenics and undifferentiated schizophrenics) using SIS-II observed that the trend of mean scores for pathological groups was almost similar where the highest mean score was amassed by the human responses category, followed by the most-typical, anatomical, animal, human movement, rejection, animal movement and sex categories. The depressive neurotics, paranoid, and undifferentiated schizophrenic groups, however, followed a slightly different pattern where the mean sex responses outnumbered animal movement responses. Psychometric Properties 25

A comparison of means of the pathological and normal groups shows that the SIS can clearly distinguish the patients on the indices of rejection, animal movement and sex responses. The mean rejection scores of normal subjects was 0.58, SD=1.40, while the mean scores for pathological groups were invariably higher. The highest mean rejection has been obtained by the paranoid schizophrenic group followed by the undifferentiated schizophrenics, anxiety neurotics, and depressive neurotics. A similar picture emerged for the other two indices where pathological groups overshadowed normals. However, the mean scores for the animal movement by undifferentiated schizophrenic group was slightly lesser than that of the normal group. It can be safely concluded that the indices of animal responses, most-typical responses and rejection of images very well differentiate normals from four pathological groups. Hence, these can be taken as hard-core indicators. Other indices such as total number of responses, anatomical responses, human movement responses, and human responses have been found to differentiate normals from undifferentiated schizophrenics. The schizophrenic patients are known to have thinking disturbances. Therefore, their imagination for SIS images is likely to differ greatly with normal subjects. The present findings support the contention of Cassell et al (1995). Table-8 displays the ‘t’ values obtained from the intergroup comparisons for various scoring indices of the SIS-II test. The normal subjects elicited more number of total responses on SIS-II than the four pathological groups. The paranoid and undifferentiated schizophrenics have given significantly lesser number of total responses than either normal or anxiety neurotic groups. Normal subjects gave the lowest number of anatomical responses than the four pathological groups, which goes hand in hand with the animal response category. In the anatomical response category the normal subjects and undifferentiated schizophrenics have shown a statistically reliable difference (t=2.49, p <0.05) while other groups have failed to do so. This pattern of results is contrary to the often-voiced emphasis placed on the SIS test. It is however, possible that qualitatively anatomical responses might be different in five groups. A normal subject is likely to elicit anatomical responses on the images structured to elicit anatomy. The clinical groups divided somatic imagery on images meant to elicit it and perceived anatomy on the structures generally not stimulating any anatomy. This process of evading reality and the theory of somatic repression support such findings (Cassell, 1979, 1980b; Croog et al, 1971; Savage, 1995, 2001). The normal subjects have emitted less number of sex responses as compared to the four pathological groups. Higher mean number of sex responses by the paranoid schizophrenics with reference to their delusions of infidelity supports the observation of most researchers on the SIS. The mean number of human movement responses by the normal subjects has been found to be quite high and it is almost similar to that of Psychometric Properties

depressive neurotics. A similar pattern of responding was evident for animal movement category where the mean of normal group was less than most of the pathological groups. However, none of the comparisons reached a level of statistical significance. The mean number of most-typical responses by the normal subjects was higher than that of the four pathological groups. Significant differences were found among most of the groups. Normal subjects rejected significantly lesser number of images than did the four pathological groups. The two schizophrenic groups rejected more number of inkblot images than did their neurotic counterparts. Table 8 Inter Group Comparisons for Different Scoring Categories of the SIS-II Scoring NvsA NvsD NvsPS NvsUS AvsD AvsPS AvsUS DvsPS DvsUS PSvsUS Indices Total (R) 0.11 1.36 3.03** 3.49** 0.87 2.03* 2.14* 1.56 1.71 0.10 Human 0.94 1.07 1.47 3.79** 0.07 0.57 2.30 0.63 2.75** 1.46 responses Animal 3.32** 2.78** 2.13* 3.15** 0.56 0.75 0.18 0.25 0.70 0.87 responses Anatomical 1.11 1.92 0.31 2.49* 0.59 0.56 1.34 1.12 0.86 1.77 responses Sex 0.07 0.46 1.71 0.80 0.20 1.24 0.44 1.33 0.11 1.00 responses Human 1.96 0.03 0.49 2.22* 1.46 0.96 0.35 0.42 1.70 1.21 movement Animal 0.62 0.21 0.60 0.62 0.35 0.23 0.86 0.42 0.71 0.89 movement Most-typical 6.96** 5.64** 15.94** 17.06** 0.62 10.84** 12.00** 10.67** 11.76** 0.76 responses Rejection 3.16** 2.53* 3.60** 3.62** 0.33 1.79 0.24 1.93 1.65 0.42 Mishra & Dwivedi ( 1997 ) * p < 0.05; ** p < 0.01 These results suggest that most-typical responses, rejection of images, animal responses and total number of responses are hard core indicators in differentiating normal subjects from the four pathological groups. Human and human movement responses can also be considered as second order indicators, which discriminate undifferentiated schizophrenics from normal subjects. However, sex responses, and animal movement responses could not prove to be diagnostic indicators in this study. Undifferentiated schizophrenics and paranoid schizophrenics gave lower number of most-typical responses, less number of total responses and human responses with Psychometric Properties 27

higher number of rejection of images. These four indices i.e. low R, low H, low MT and high rejection of images may be taken as indicators of undifferentiated and paranoid schizophrenia (Dubey et al, 1995). Anxiety neurotics and depressive neurotics gave more animal responses, rejected more images and gave less number of most-typical responses than the comparable normal controls. These results suggest that these three indices can help in discriminating anxiety neurotics and depressive neurotics from the normal subjects. Table 9 Multiple Discriminant Function Analysis in Terms of U-Statistic & Corresponding F-Ratios for Identifying the best Predictors of SIS- II Scoring Indices U- Statistic Approximate F- Degrees of Statistic Freedom Total No. of Responses 0.2979 29.957*** Anatomical Responses 0.2830 19.290*** Animal Responses 0.2652 14.774*** Human Responses 0.2552 11.936*** Sex Responses 0.2473 10.049*** Animal Movement Responses 0.2422 8.649*** Human Movement Responses 0.2369 7.621*** Most Typical Responses 0.2273 6.983*** Mishra (1996) The diagnostic certainty of the SIS-II and the Rorschach was also ascertained by applying the statistics of multiple discriminant function analysis and shown in table 9. The U-values and their corresponding F-values demarcating the diagnostic compatibility of the SIS with the Rorschach test showed the popular responses {U = 0.2231, F (4,145) = 126.25, p < 0.001} of Rorschach as the best indicator followed by human movement and total number of responses. On the other hand, the anatomical responses of SIS stepped out as the best predictor {U = 0.0971, F (24,490) = 19.408, p < 0.001} followed by animal responses of Rorschach and animal movement responses of the SIS-II. All the indices of the SIS-II were found to be as powerful discriminator as were found for the Rorschach test, which establishes the diagnostic certainty of the SIS-II. The contention of Cassell et al. (1995) that SIS-II is an extension of the Rorschach thus gets statistically supported (Cassell et al,1995). It also validates the discriminating power of SIS-II, and as SIS fares quite well with the Rorschach, the parallel status of the SIS is established by the present findings (Mishra, 1995). Table 10 presents the percentile norms for the nine SIS indices. These norms extend some interesting features of responding by the normal control subjects. These norms also vindicate the contention that this test can easily discriminate normal subjects from Psychometric Properties

other pathological groups. Although this holds true for all the nine indices used in the present study, yet some factors clearly stand out as hard core markers which need to be briefly mentioned. Total responses emerge as a key marker in as much as it is Table 10 Percentile Norms Based on the Responses of Normal Controls for Nine Scoring Indices of the SIS-II Percentile Total H A Anato- Sex Human Animal MT Rej Points R mical Move- Movement ment p100 p95 p90 p85 p80 p75 p70 p65 p60 p55 p50 p45 p40 p35 p30 p25 p20 p15 p10 p5 Mishra & Dwivedi (1997 ) noticed that at p5 there are 55 responses, which reach up to 79 at p100. The median point of this index is 66. In other words, this index clearly discriminates normal subjects Psychometric Properties 29

from other groups. The index of human responses is another potent marker where the scores range from 14 to 31 with median at 21. The scores of pathological groups on this index is much less. The animal responses are lesser in normal controls, which range from 2 to 20 with a median at 8. The index of rejection shows zero response up to p70 while the pathological groups evince much higher rejection of images. The norms derived on the basis of the normative sample of the present study have, however, drastically limited value and it needs to be further enriched by administering SIS-II on a much larger group. From Table-11, it is evident that alcohol dependent cases who ‘improved’, differed significantly from the cases who ‘failed to improve’ in respect to most of the SIS-II indices i.e. ‘Total number of responses’, ‘Movement’, ‘Animal’, ‘Human’, ‘Sex’ and ‘Rejection of Images’. The ‘improved’ category of alcohol dependent cases were significantly more likely than ‘failed to improve’ cases to give less number of ‘Total’, ‘Movement’, ‘Animal’, ‘Sex’ and ‘Rejection of Images’ categories of responses. On the other hand, ‘improved alcohol dependent cases gave significantly more number of ‘Human’ responses in both the groups, did not differ significantly in respect to ‘Anatomical’ and ‘Most typical’ categories of responses. Table 11 Comparison of SIS Indices for Alcohol Dependent Group (n=50) SIS Indices No. of Patients Patients Failed Level of Resp. Improved to Improve Significance (n = 32) (n = 18) Total Responses < 70 90. 62% (29) 33. 33% (06) .01 Movement < 15 81. 25% (26) 38. 88% (07) .05 Animal < 9 81. 25% (26) 33. 33% (06) .01 Human > 15 90. 62% (29) 55. 55% (10) .01 Anatomical > 12 84. 37% (27) 61.11% (11) N.S. Sex < 3 78.12% (25) 50. 00% (09) .05 Rejection of Images < 1 87. 5% (28) 61.11% (11) .05 Most Typical > 13 78.12% (25) 55. 55% (10) N.S. Dubey and Singh(1997) Figures in parenthesis indicate number of cases From Table-12, it is apparent that at least four indices of SIS-II could discriminate significantly both categories ‘improved’ and ‘failed to improve’ of drug dependent cases. The ‘improved’ category of cases are likely to give significantly more number of ‘Total R’ and ‘Anatomical’ responses on one hand and significantly lesser number of ‘Movement’ and ‘Sex’ responses on the other hand than the ‘failed to improve’ category. Unlike Psychometric Properties

alcohol dependent group, the ‘Animal’, ‘Human’ and ‘Rejection of images’ did not discriminate significantly both the categories of drug dependent cases. Table 12 Comparison of SIS Indices for Drug Dependent Group SIS Indices No. of Patients Patients Failed Level of Responses Improved to Improve Significance (n1 = 32) (n2 = 18) Total Responses > 66 85.18% (23) 60. 86% (14) .05 Movement < 10 74. 07% (20) 39.12% (09) .05 Animal < 10 66. 66% (18) 52.17% (12) N.S. Human > 15 81. 48% (22) 60. 86% (14) N.S. Anatomical > 13 81. 48% (22) 39.12% (09) .01 Sex < 3 88. 88% (24) 65. 21% (15) .05 Rejection of images < 1 81. 48% (22) 73. 91% (17) N.S. Most Typical > 10 74. 07% (20) 65. 21% (15) N.S. Dubey and Singh (1997) Figures in parenthesis indicate number of cases. Table 13 Pathological Indices in Normal and Clinical Groups Pathological Indices Normal Neurotic Schizo- Chi-square phrenic and p Disorder Perseveration Present X2 = 16.06 Absent p = .01 Pathological Anatomy 0-1 X2 = 0 Score 2 & Above p = n s Hostility Aggression 0-2 X2 = 0.02 Score 3 & Above p = n s Depression Score 0-1 X2 = 0. 05 2 & Above p = n s Paranoia Score 0-1 X2 = 7. 84 2&Above p = 0. 01 X2 = was calculated combining normal, neurotics and schizophrenics together. Table-13 reveals that, using the available definitions of pathological scales, only a limited number of responses qualified to indicate the Pathological Anatomy scale, the Hostility and Aggression scale, Depression and Paranoia. Even then, in Schizophrenics, Psychometric Properties 31

a significantly large number of subjects obtained Paranoid score above the cut off points of 2, compared to Neurotics and Normals. Perseveration was clearly seen more in psychotic cases than neurotics and normals. The results of validity studies suggested that the test has significant construct, content and discriminating validity to a great extent. Further studies are definitely required for more detail on different groups from different countries. Normative Data To give a better understanding to one having less exposure to SIS procedure, images assessing different areas are shown in table 14. Table 14 SIS Images Assessing Different Areas Area Images Interpersonal Relationship A - 9,21,24,28,31 B - 4,5,28,31 Ego/Self Image A - 5,6,7 B - 22,27,28,29 Healthy Body Imagery A - 10,12,13,14,15,16,17,18,19,20,22,23 B - 9,11,16,17,20,30 Erotic Imagery A - 4,8,22,25,27 B - 18,25 Hostility / Aggression B - 15,21 Insecurity A - 13,24,26 - B - 19 Thinking In Group Conformity A - 7,9,13,20,23,27,30,31 B - 4,5,9,22,27,28,29,30,31 Reproduced from Dubey, Cassell, Pershad & Dwivedi (1995) Some more data on SIS Video and its comparison with SIS-II and Rorschach test has been shown in further tables for its compatibility and better understanding. The SIS-Video stimulates the subjects more than SIS-II leading to more number of total responses (R=74.08). The percentage of responses under the category of Movement, Human, Animal, Anatomical and Most-Typical responses had been different in the two sets. Movement responses were more in SIS-Video images whereas images are static in SIS-II. The table does not indicate much difference in the scoring categories except for the percentages of response in Movement, Human and Anatomical categories as shown in Table 15. Psychometric Properties

Table 15 Comparison of Responses on SIS-II & SIS-Video in Healthy Normals Frequency per Protocol Categories SIS-II* (n=100) SIS -Video* (n=100) Total Number of Responses 69. 50 74. 08 Movement Responses 5. 00 (7.19) 9. 60 (12. 96) Human Responses 17. 40 (25.02) 14. 66 (19. 79) Animal Responses 9. 20 (13.22) 8. 65 (11. 68) Anatomical Responses 12. 20 (17.55) 9.18 (12. 39) Most-Typical Responses 12. 00 (17. 26) 13. 68 (18. 47) * Reproduced from Dubey and Cassell (1993) Mean Percentages are given in parenthesis Table-16 suggests that the responses in series A and series B are almost proportionate. The correlation for the different scoring categories are significantly high except for Most-Typical responses where the range of scores is less hence correlation was low but still significant beyond .01 level. Table 16 Comparison of Responses on Series A & Series B of SIS-Video Categories Series A Series B r Total Number of Responses 40.10 33. 92 . 86 Human Responses 18. 60 21. 46 . 56 Animal Responses 12. 64 10. 11 . 60 Anatomical Responses 12. 42 12. 17 . 59 Sex Responses 6. 08 5. 07 . 45 Movement Responses 14. 01 11. 82 . 59 Most-Typical Responses 17. 46 19. 28 . 39 Rejection of Images 0. 57 1. 71 . 74 Reproduced from Dubey et al, (1995) r is shown in Mean and other Categories in Mean percentage Table-17 suggests that 62 images of SIS-II/Video are able to discriminate normal subject from neurotic and schizophrenic disorder. Certain indices are able to differentiate within the clinical groups, neurotics & schizophrenic disorders. As evident the total number of responses is more in normal than the other two groups. Normal subjects give more of Most-Typical responses and schizophrenic disorders the least. Neurotics Psychometric Properties 33

are in between. Similar trend is found in Typical responses also. Atypical responses are more in schizophrenic disorder and least in normal subjects. Neurotics are again in between. Human responses have not been able to differentiate the groups, except that the quality of human responses is poor in schizophrenic disorder. Animal and Anatomical responses are more in schizophrenic disorders than in the normal group. Movement responses are unable to discriminate the groups. Rejections of responses are much higher in clinical groups and lowest in the normal group. Pathological responses are almost absent in the normal group. Neurotics give more of Hostility Aggression score and Depression Score where as the Schizophrenics give more of paranoid and Pathological Anatomy Score. On the basis of the results, Most-Typical responses, Rejection, Pathological Scores and Atypical indices are found to be hard-core indicators and H, A, Anatomical and Sex as soft-core indices. The findings are shown in Table-17 Table 17 Diagnostic Indicators of SIS-II / Video Indices Normal Neurotic Schizo Disorder n = 300 n = 100 n = 100 Total Response 61-75 53-65 50-65 <62 <59 <62 Most Typical Response(out of 18) >13 <11 <08 Typical Response >50% 35-50% <30 % Atypical Response <12% 15-20% >20 % Human Content 20-25% >25% >25 % With Poor Form Animal content <11% >12% >16 % Anatomical Content <15% >15% >18 % Sex Content About 6% About 4% About 6 % Movement <13 <08 <10 Rejection of Images <01 Image >05 >04 Pathological Almost More of HAS More of P Response(PAS,HAS,D,P) Absent & Depression (Paranoid) & PAS Reproduced from Dubey, Cassell, Pershad & Dwivedi (1995) Hard-core Indices: MT, Rejection, Pathological, Atypical Soft Indices: H, A, AT, Sex Analysis Based on Data Published in SIS Jr. of Proj. Psy. & Mental Health - (1994) and Brit. Jr. Proj. Psy (1993) on over 500 cases. Keeping the above indices in view the SIS was tried during the selection of employees as a screening test. The findings are very encouraging. The subjects who did not reject Psychometric Properties

any images, gave more than 13 MT responses, more then 20 percent of Human responses, less then 15 percent of Animal and Anatomical responses and no pathological responses were recommended for inclusion. However, none was rejected on the basis of psychological test. Selection was finalized on the basis of overall performance in the interview. Indices found successful are shown in table-18. Table 18 Successful SIS Indices Indices Scores Rejection of Images Less Than 1 Percent Most Typical Responses More Than 13 (out of 18) Human Responses More Than 20 Percent Animal Responses Less Than 15 Percent Anatomical Responses Less Than 15 Percent Pathological Responses Almost Absent Reproduced from Dubey, Cassell, Pershad & Dwivedi (1995) Table 19 SIS Video Responses of Executives in India Indices Telephone Private Public Public Cables Sector Sector Sector (n=90)* (n=300)** (n=400)** (n=102)* Total No. of Responses 65.57 70.25 66.50 Human Responses 19.21 14.20 20.30 (30.96) (28) Animal Responses 7.31 8.45 10.65 (12.75) (11) Anatomical Responses 12.38 11.40 11.80 (19.97) (19) Sex Responses 2.24 4.20 3.30 (3.62) (4) Most Typical Responses 15.24 14.55 14.55 (85) (83) Movement Responses 6.31 8.35 5.75 (10.18) (7) Rejection of Images 0.35 0.75 0.85 0.40 (0.20) (0.60) Pathological Responses 0.19 Almost Almost 0.14 (0.21) Nil Nil (0.20) *Dubey et al (2001) Percentage given in paranthesis. **Data presented in APA Annual Conference Aug. 2001 Sanfrancisco and Aug. 2002 Chicago. Psychometric Properties 35

Table 19 suggests that Executives have shown high productivty, creativty and good interpersonal relationships. The aggressive responses were within normal range. They had healthy body imagery and erotic perception. Rejection of images and Pathological responses were found to be negligible. As a whole they showed healthy normal profile. Table 20 Comparison of Adults with Adolescents Percentage of Responses in Categories Adults ( n = 100 ) Adolescents ( n = 48 ) Human 19. 79 34. 46 Animal 11. 68 6. 39 Anatomical 12. 39 22. 08 Sex 5. 56 2. 46 Movement 12. 96 1. 16 Most Typical 18. 47 11. 97 Rejection 1. 11 4. 73 Mean Response 74. 08 59. 31 Reproduced from Dwivedi, Mishra and Cassell (1994) Table 20 suggests that adolescents differed significantly on different SIS indices when compared with adults. This is possible because of the differences in their maturity level and interests. Table 21 Comparison of Series A & B in Adolescents Scoring Series- A (n=48) Series- B (n=48) Categories Mean Percent (%) Mean Percent (%) No. of Responses 29.79 29.52 Human Responses 9.56 32.09 10.88 36.86 Animal Responses 2.29 7.69 1.50 5.08 Anatomy Responses 7.06 23.70 6.04 20.46 Sex Responses 0.83 2.79 0.63 2.13 Movement 0.19 0.64 0.50 1.69 Most Typical Responses 3.77 12.66 3.33 11.28 Rejection 1.25 4.20 1.56 5.28 Dwivedi, Mishra and Cassell (1994) (None of the responses between series A & B differed significantly) Psychometric Properties

None of the indices between Series A and Series B differed significantly as shown in Table 21. Fifty Normal, fifty Neurotics (Anxiety & Depression) and fifty with Schizophrenic Disorder were given SIS and Rorschach and their protocols were scored on nine indices. X2 test suggests that both the test are compatible on following nine indices as shown in Table-22. Table 22 Compatibility of SIS-II and Rorschach Indices in Normal and Psychiatric Groups Scoring Indices Obtained X 2 Values Significant Level Total Number of Responses 5.02 ns Human Responses 2.86 ns Animal Responses 4.11 ns Anatomical Responses 0.78 ns Sex Responses 0.36 ns Human Movement Responses 5.79 ns Animal Movement Responses 1.21 ns Most-Typical Responses 4.04 ns Rejection of Images 1.51 ns Mishra (1996) Values of Kendall’s coefficient of concordance between the nine indices of SIS and Rorschach (Table 23) could reveal significant relationship suggesting their concordance on nine indices. The SIS appraises the same construct as the Rorschach test. However, because of its emphasis on self-administration, it moves beyond the Rorschach. Table 23 Kendall’s Coefficient of Concordance between the 9 Indices of SIS-II and Rorschach Group w n k Significance Level Normal .85 .01** Anxiety .82 .01** Depression .77 .01** Schizophrenic Disorder Paranoid Type .77 .01** Schizophrenic Disorder Undifferentiated Type .74 .01** Mishra , M - 1995 ** p = .01 Level Psychometric Properties 37

It can be concluded that Somatic Inkblot Series Test is a reliable and valid test. Various types of reliability such as Test-Retest reliability, Split-Half reliability and Parallel Form reliability were found very high. The test has high content validity. Both the series A & B have high correlation and can be used independently for quick assessment; however, administration of the full test is necessary for complete assessment. The test is able to discriminate normal subjects from clinical groups (Anxiety Neurotics, Depressives, Schizophrenics, Alcoholics, Drug Dependents and many more). The Rorschach test and the SIS were compared on nine common indices such as R, H, A, M, FM, Anatomical, Sex, Rejection, and Most Typical/ Popular and found compatible. The SIS appraises the same construct as the Rorschach test. However, due to the use of self-administration and video technology it reaches beyond the Rorschach test. The Somatic Inkblot Series has taken care of the lacunae of Rorschach test and does the Father of Inkblots, Hermann Rorschach, start carrying on the work. Psychometric Properties

Administration Procedure and Instructions The objective of this Introduction and Guide is to describe the SIS-II booklet and the videotape version of the SIS-II, both of which are provided with the basic procedure kit. The purpose is to present administrative and interpretive guidelines for the professional use of the procedure. The booklet serves to collect personal information, such as age, gender, education and other relevant health data separated from the pages for personal responses to the images. The reason the subject is asked to complete the health questionnaire immediately before viewing the Booklet or Videotape is to bring to mind any physical problems. This momentarily creates a perceptual set for projecting clinically relevant material. As appropriate or necessary, the response form booklet can be used by itself, independent from the video application. A unique advantage of the SIS procedure is that it can be “self-administering” should the therapist, counselor, psychologist, physician, research scientist, or educator find it appropriate to application circumstances and goals. Video Procedure When the SIS video is to be presented in the professional’s office, the assessment room needs to be equipped with a color television monitor and a videocassette recorder (VCR). In addition to comfortable seating for two or more persons, it is best to provide a small table or desk to facilitate the writing of observations and responses in the answer booklet. Adequate and adjustable lighting and privacy from interruption and extraneous sounds will enhance the experience of the procedure. The initial instructions and assistance provided by the professional will induce the relaxed mood intentionally cultivated on video. This is accomplished through the use of pictures of flowers, peaceful scenes of natural environments and musical interludes. A calm mind and semi-hypnotic state will serve to promote the release of deeply repressed and/or painful material that might never be recalled. Ordinarily, traumatic material is less likely to be verbalized directly in an interview situation or through non-projective psychometric tests. The professional will provide full disclosure of potential benefits and risks associated with each procedure administered. This assures fully conscious and voluntary willingness to enter into the experience. Risks include the potential to bring repressed or controlled post-traumatic experience and feelings into full awareness. In most instances, similar to a subject’s experiencing dreams or “nightmares,” the SIS viewer is able to reconstitute psychological defenses immediately afterwards. In rare instances, the professional needs to be available to assist. Fortunately, there has been no reported instance of major or lasting effects. For children and adolescents, appropriate informed consent must be obtained from a parent or legal guardian. If, for any reason, the Administration 39

examiner is concerned about the potentially disruptive impact of the SIS Video (e.g. psychotics, borderlines, etc.), the procedure is available in a black and white version, which elicits content without the potentially emotionally disruptive color shock. A salient and dramatic benefit is the identification of forgotten, traumatic experiences. In certain cases, the identification of these may serve to inhibit mental mechanisms and subvert effective coping with present life situations. When the video tape version of the SIS-II was completed in 1984, it was intended primarily for supervised administration by a professional in an office or hospital setting. Subsequently, it has proven to be useful in-group situations. With certain individuals who are psychologically intact, the administrator may choose to give the SIS as a “take-home” assignment. The subject is instructed to complete the procedure in the evening in a relaxed setting, when psychological defenses are lower. The viewing of the threatening images immediately prior to sleep may serve to stimulate dreams of a clinically relevant nature. As part of the instructions, the individual is asked to record any such material and bring it to the follow-up interview for detailed inquiry. This is normally scheduled for the following morning. In the interview situation, the administrator starts by exploring associations to, and feelings about, the images which were originally rated as the three most-liked when the answer booklet was completed. If more rigorous documentation is required, the follow-up interview may be recorded on audiocassette or videotape, depending on the interviewer’s preference. The review of this material is designed to relax the subject and open the session for the subsequent exploration of more painful material, often elicited from those that are rated as most threatening. Rarely, it may serve as a base to which the interviewer can return, if the emotional impact of the latter material is too threatening. Upsetting life experiences serve to inhibit or subvert effective and satisfying coping with present life situations. Benefits throughout the history of formless stimuli and projective instruments trace back to the fifteenth century (Zubin, Eron & Schumer, 1965). They include stimulation of creative imagination and generation of data for study of thought processes, reflex hallucinations, intelligence, personality and psychopathology, in addition to the potential for making audible and understandable “the inner cry.” This is consistent with what the Greeks referred to as emotional catharsis. The videotape version is primarily intended for supervised administration by a trained professional as an adjunct to individual counseling, therapy or industrial consultations. In addition, it has proven useful in-group sessions and as a “take-home” assignment at bedtime to stimulate dream material. When asked to give an opinion about the SIS video procedure in 1990, Wayne Holtzman, Ph.D., internationally respected developer of the Holtzman Inkblot Series (Holtzman et al, 1956), said, “Unlike many other methods, it is particularly appealing when used by the clinician and subject in an interactive, interpretive mode as part of the total diagnostic-treatment process. The dynamic nature Administration

of the stimulus, when presented by videotape in full color, reaches well beyond the limitations of traditional projective techniques.” [For a brief history of projective and inkblot assessment methods, see Historical Development of Inkblot Technique.] The SIS-video is unique in the principles it uses to make the individual’s “inner cry” audible and in the way it uses video technology to access the deeper layers of consciousness to draw out the response. Television is an almost universal form of entertainment. There is a television set in almost every home. It is a part of our everyday lives and, therefore, non-threatening. In their book, “Television and the Quality of Life: How viewing Shapes Everyday Experience,” (1990) Robert Kubey and Michaly Csikszentmihally report that when watching television there is an altered state of consciousness with reduced concentration and heightened passivity. This makes it possible to employ principles known by hypnotists. Specifically people under a hypnotic trance or altered state of consciousness can respond to questions that they might not be able to in a normal conscious state. Viewing the SIS- video, like dreaming, can be an emotional and cognitive experience, which has therapeutic value. Procedure guidance is provided verbally on the videotape and is printed in the Response Form Booklets. The booklet presents the same sequence of images as the video; however, booklet images are blue to avoid color shock. As indicated, initial attention is given to the three images identified as “Most Liked.” Consideration is given to responses reflecting health, emotional maturity, positive outlook and other reflections of ego strength. The insight obtained from these responses is important, since post-procedure inquiry and therapeutic follow-up, ideally, always begin with the positive responses. Starting with the positive serves to reduce the subject’s anxiety and reassures him/her that he is basically okay psychologically. From positive feelings, it is easier to move into negative areas of imagery. The therapist may choose to return to the positive images for closing post-procedure inquiry and follow-up therapy sessions to bolster the subject’s psychological defenses. The first step for professional analysis and interpretation of responses involves studying the three responses that the patient considered “least liked,” along with the reason(s) for their negative impact. Next, the responses for the entire series of 62 images are scanned for psychopathological material, such as responses depicting humans in conflict or suffering, diseased anatomy responses, symbolic anatomy (e.g. broken heart as a sign of depression), excessive sexual content, etc. Perseveration of a theme, from one image to another, may suggest important unresolved material on a constant issue (i.e. repeatedly seen fetuses in someone who had repeated miscarriages). Alternatively, it may signal the need to consider the diagnostic possibility of neuropsychological impairment. Administration 41

SIS procedures lend themselves to working with individuals whose first language is not English, and with those who have different cultural or socialization histories. Instructions are available in a number of languages. Also, most human figures use a color/form not specific to a particular race. As with other modes of assessment or diagnosis, interpretation of responses as typical or atypical is dependent upon normative comparisons with responses from peers, or their populations of interest, such as high achievers in the responder’s school system; hospitalized patients; young mothers; unmarried males; etc. Because of the potential to provide information of psychological significance and therapeutic value, somatic imagery theory is reviewed briefly in a following section. Examination Instructions This viewing procedure is to be administered under the direct supervision of a trained professional who has explained its risks/benefits, clinical relevance and value in better understanding your problems. If, at any time, questions or difficulties should arise during or after this procedure, please feel free to contact your clinician who will be pleased to assist. Before the clinician administers the SIS procedure, it is important that a reasonable comfort level is established with the person who is to view the SIS images. The professional may begin by going over the instructions listed on the back page of the answer booklet. First, have the subject fill in the brief health history. Explain that a series of flowers will be shown to help the person relax. Next, indicate that there will be video instructions on how to fill in the answer booklet. Turn the booklet over and point to the example at the top of the first page. Tell the person that he is to simply label the images, just like in the example, and to include any emotions that relate to each image. Then turn to the back page of the booklet and ask the individual, upon completion of the 62 images, to first select the three images that they liked most, and then, the three images least liked, and the reasons why they chose those particular images. Finally, ask if there are any questions concerning the procedure. Instruct the subject to start and inform him where you will be, in case there are any problems. Also indicate that if more time is needed to look at or write down something concerning an image, the VCR may be stopped. The reason for introducing the health history moments before the video procedure is to bring to mind any present or past health issues. This material in short-term memory subsequently creates a perceptual set to project clinically relevant responses. The soft music, in association with repetitive relaxation commands, creates an artificially semihypnotic state. Like the subject in a trance, this electronic technology serves to pull the subject out of the test reality into the imaginary television world. These initiates a fantasy voyage, which takes the viewer back to earlier space-time, coordinates when unresolved traumatic events wounded the ego. To reverse the trip, the video concludes with relaxing Administration

nature scenes, which serve to return the individual to the present time/space reality of the clinician’s office. If the examiner’s previous clinical evaluation indicates that the subject is fairly stable, the video and booklet can be taken home for viewing at bedtime. This may serve to stimulate therapeutic dreams and is illustrated in ‘Case-7’. When the subject indicates that the viewing is complete, it is necessary to conduct a short debriefing interview. This is to ensure that the procedure was completed according to the instructions. Reassure the subject that things have gone well. It is very important to make certain that no special therapy techniques are required to assist the individual if unduly painful material has been released. The examiner’s detailed inquiry is scheduled for the next day. The viewer is reminded to record any dreams that may be released. The professional should be available for the next several days in the unlikely event of a delayed emotional response. The busy clinician may not wish to deal with associations to any other images than the ones “most-disliked,” because at any one testing time, these three represent the heart of the procedure. Unlike other inkblot tests, it is not necessary to obsessively review the responses to all 62 images, unless one is doing a formal psychological report or conducting research. In the instance of pathological or deviant responses, the inquiry is aimed at discovering positive or negative cathexis of specific body regions. The professional might ask, “Has this any relationship with your personal life, or the life of your loved ones? Have you viewed similar images in your past life, dreams or fantasies?” SIS-II Booklet Procedure The booklet version of the Somatic Inkblot Series (SIS-II) can be used in a variety of ways but was designed for self-administration after supervised instruction. The subject is provided eight pages booklet consisting 62 images in two series A and B each with 31 images and asked to read the instructions printed on last page of the booklet. “ Most people find this test fun and interesting. First, please relax, take a few deep breaths, and prepare to enjoy. Please turn this booklet over, and study the sample response. Notice that you may write on the picture or in the space below it. Label each in terms of what they resemble or look like to you. Please include everything you see even if it reminds you of something remote, vague, dreamlike, highly personal or even potentially embarrassing. Please include everything you see with as much detail as possible. Also include any outstanding emotional reaction that might occur in responding these images. Please begin on the first page study the sample, and continue until completed.” The subject is asked to complete the identification data and the brief health history as instructed in video procedure. Reassure the subject that: 1. There are no right or wrong answers. 2. Different people see different thing in the inkblots. Administration 43

3. It is important to write whatever the inkblot looks like regardless of whether or not it makes sense or how it might seem to others. 4. The test may take about one hour in its completion. Like video procedure, the subject is asked to select three image which (s)he liked the most and three images which (s)he liked the least. After the completion of the test, the clinician will quickly go through the responses and will decide if an specific response needs further exploration. This helps particularly in understanding the psychopathology behind an “Atypical response” or a response helping in hearing the inner cry of the individual. Except the procedure of presentation (Booklet Form or Videotape), both the procedures follow the same administration. Benefits It is readily apparent that the SIS instrument has many applications in traditional medical and psychiatric populations. When the SIS was first developed its research and diagnostic uses were given high priority. With time and experience, it became evident that employing this technology in clinical populations had value as an adjunct to traditional therapy procedures. In certain instances, the SIS proved to shorten the time of treatment and to be cost effective. Because it is a video procedure that is linked to computerized scoring, it has multiple additional applications, especially in screening candidates for the military and law enforcement agencies. Why hire an individual who may have long-forgotten, repressed traumatic life experiences in employment situations where there is a high occupational risk of further trauma? Such persons have a lower threshold to future job-induced stress, which could jeopardize the effectiveness of a particular group or company. The SIS procedure can be employed as a measure of the effectiveness of any treatment program which deals with traumatized individuals (e.g. soldiers and policemen). If these people do not have appropriate early identification and active therapy, they will be at high risk to develop alcohol and drug problems, physical symptoms, mental disorders and a variety of behavioral difficulties. Administration

Scoring and Charting Definitions of Scoring Indices Mental health professionals with training and experience in projective techniques will have little difficulty integrating the scoring and charting conventions used with the Somatic Inkblot Series. “Body Symbolism” (Cassell, 1980), can be a resource for increasing one’s skill in the interpretation of the original 20 cards SIS responses. Since the procedure conceptually taps into the same stream of imagery as seen in dreams, daytime fantasies and visual hallucinations, a background in interpreting such content, either in a direct or latent symbolic way, is helpful. Clinicians experienced in art psychotherapy will readily adapt to this technique (Kwiatkowska, 1978; Ulman, 1965). They will find the SIS a useful aid, especially for people who cannot draw. In a sense, the SIS employs art as a diagnostic and therapeutic approach for those who cannot engage in traditional art procedures. Other clinicians with experience in dream interpretation, visualization techniques, guided imagery, active imagination therapies and hypnotherapy will also readily adapt to this procedure. There are variations in test-taking, with important clinical applications. People who have difficulty in completing the test and who do not respond to a number of video images may be exhibiting denial, avoidance, blocking or repression. Excessively detailed responses suggest obsessive-compulsive traits. Exaggerated verbal responses, while discussing inkblots least liked, suggest affect-laden content. This should be further explored for relevance and meaning to the individual. In some cases, repressed material can burst into conscious awareness, triggered by the semiambiguous inkblots. The underlying dynamics of many somatic complaints and personality traits can become accessible with this technique. The eleven categories found to be important in understanding and interpreting protocols are: 1. Total Number of Responses 8. Typical Responses 2. Human Responses 9. Atypical Responses 3. Animal Responses 10. Rejection of Images 4. Anatomical Responses 11. Pathological Responses 5. Sex Responses a. Pathological Anatomy (PAS) 6. Movement Responses b. Depression (D) 7. Most Typical Responses c. Hostility and Aggression (HAS) d. Paranoia (P) Each category is designed to stimulate consistency among the raters, and to afford commonality in acquiring information for research and normative data collection. The Somatic Inkblot Series has a very simple scoring system. It is less complicated than existing inkblot tests, since it emphasizes content analysis. The scoring categories have been descrived as follows :

1. Total Number of Responses ( R ) The total number of responses is arrived at by counting all the responses given by the subject on the 62 images of the SIS-II / Video. This number suggests imaginative capacity and functioning intelligence of the subject. Psychiatrically ill patients will have a poor imaginative capacity and poor functional intelligence. 2. Human Responses ( H ) Human responses include the whole human body, or external parts of the human body like face, ear, nose, legs, etc. The category does not include mutilated forms of the whole body or parts of it, such as crushed human being, broken legs or smashed face. These mutilated responses are included in the Anatomical responses. The number of Human responses suggests subject's interpersonal relationship with human beings. When responses are low, it might be indicative of a desire to be away from others and indicative of schizoid or social isolation tendencies. 3. Animal Responses ( A ) Animal responses include living or dead animals such as wild and pet animals, reptiles, birds and sea animals. This category also includes external parts of the animals such as wings, legs, claws, beak, etc., but it does not include mutilated parts of the whole animal such as crushed birds or animals, pulled out wings, etc. Whenever a large number of animal responses are given, interpretation should be that the respondent is more comfortable with animals than people or psychologically immature. 4. Anatomical Responses ( At ) Anatomical responses pertain to internal parts of living beings and their mutilated forms, both of humans and animals. These responses are consistently high in those who have a poor self image and who are preoccupied with internal body organs. 5. Sex Responses ( Sex ) Sex responses pertain to the internal or external reproductive system and to sensuous parts of the body. These responses include thighs, buttocks, breasts, fallopian tubes, ovaries, etc. Heightened anxiety and pathology may be associated with either heightened projections or impaired recognition of imbedded sexual structure. These may signify sexual anxiety and/or dysfunction. 6. Movement Responses ( M ) Movement responses indicate movement in human beings or animals. Examples include “talking human being,” “flying bird” or “running tiger.” 7. Most Typical Responses ( MT ) Most Typical responses are those which are given by more than 75 percent of normal subjects on a particular image (Dubey and Cassell, 1993). The total number of such responses are limited to 18. A higher number of Most Typical responses is suggestive of coherent, logical thinking, and ability to keep up with the demands of society. It may

also be interpreted as a measure of ego strength and team concept.The following is the list of Most Typical responses along with the images eliciting them: SIS-II A: Image Responses A7 Apple/fruit A7 Dancing lady A9 Two human beings/ladies A12 Ear A13 Raised hand A20 Kidney/lungs A27 Breast A30 Skull A31 Two faces of persons SIS-II B: Image Responses B4 Two faces of persons B5 Two persons talking B9 Kidney/lungs B22 Man/boy sleeping or resting/ dreaming and soul going up B27 Child/children B28 Mother and child/standing lady B29 Running man B30 Ears B31 Family-father, mother and two children 8. Typical Responses ( T ) Typical responses are those which are commonly seen by healthy people on a particular image. 9. Atypical Responses ( AT ) Atypical responses are those of poor quality and with vague percept, either in structure or verbalization. A response that markedly departs from the category of Typical responses is also scored under Atypical category. For example, if the viewer gives the response “flower” on image A20 it should be considered as atypical because this image should elicit body anatomy such as kidney/lungs. The number of Atypical responses is proportionate to the degree of psychological or psychiatric disturbance. Perseveration may be a sign of neuropsychological impairment, and is usually absent in normal people.

Below is a list of Typical and Atypical responses on each image: Typical and Atypical Responses (SIS-II A): Image A 1 Typical: Two people; two animals Atypical: Lungs; diseased lungs; ovaries and fallopian tubes; woman’s breast; x-ray of pelvis Image A 2 Typical: Floral arrangement; people Atypical: Heart, eye Image A 3 Typical: Space needle; cross; tree Atypical: Bleeding body part; vagina (libidinal cathexis in lesbian women) Image A 4 Typical: A horse’s face; abstract art Atypical: A mask, an eye looking at me; the Devil; a person (mother grieving loss of son) Image A 5 Typical: Clown; happy person Atypical: Woman; heart; mouth Image A 6 Typical: Person and teddy bear Atypical: Egg and teddy bear; two chromosomes; legs; lines and teddy bear (lack of gestalt in concrete thought disorder) Image A 7 Typical: Woman dancing; Eve and apple; seductive woman; apple Atypical: Male; pregnant woman; heart; rivers and island; snakes Image A 8 Typical: Man; man showing male parts Atypical: Woman’s vulva; egg and sperm; fat body or face; baby; lines

Image A 9 Typical: Man and woman dancing; hearts; two men or two women dancing Atypical: Two sets of lines; face; eyes; two ants; two animals Image A 10 Typical: Eyes; eyes out of focus; woman’s face in rear view mirror Atypical: Hazy face; crying Image A 11 Typical: Nose; auto; person sitting; leaning forward; the Thinker; runner waiting for starting gun Atypical: Person doubled over in severe pain; person doubled over all the way with head between legs; kidney excreting waste (GI problems) Image A 12 Typical: Ear Atypical: Embryo Image A 13 Typical: An upraised hand; a hand reaching for help; palm Atypical: Suffering, pleading, helpless, desperate, or attacking hand; hand in flames or reaching out of concealment to grab someone (rape victim) Image A14 Typical: Esophagus and stomach; Olympic torch carrier; airport tower Atypical: Fetus; miscarriage; sacred heart; kidney Image A 15 Typical: Stomach; bird; fetus Atypical: Kidney; dead baby Image A 16 Typical: Two love birds; heart Atypical: Two (starving) birds fighting for food; lungs; x-ray of chest; leaves

Image A 17 Typical: Chest; ribs; heart; lungs Atypical: Ugly dog; monster looking out at you; gaping open mouth; two catfish looking at evil; sea horses; heart (afraid it will stop) (death anxiety in an eight year old) Image A18 Typical: Heart; female genitalia; uterus; animal coming out of heart Atypical: Creature from outer space; atomic bomb exploding; X-ray of brain Image A19 Typical: Intestines; colon Atypical: Human penis; woman forming fetus Image A 20 Typical: Kidneys; lungs; thorax Atypical: Weight lifter (back pain detail); a bush with a spear for roots; brain; ovaries; testicles; eyes; ears Image A 21 Typical: Turtle; flying bird; babies on sides Atypical: Stretched animal skin; man flashing two children; smashed animal showing entrails; spinal disc Image A 22 Typical: Spinal column; chest; rib cage; pelvis; phallus Atypical: Male genitals burrowing; funny face with low forehead (lower part); man-eating plant (upper part) Image A 23 Typical: Spinal column Atypical: “Mind block” (rape victim repressing male genital symbolism); pots, pans, or plates stacked on each other (neutralizing defense against phallic symbol by rape victim) Image A 24 Typical: Female pelvis; people Atypical: Demons or devils

Image A 25 Typical: Vagina Atypical: Stained glass window; crucifix (substituting religious symbolism); cave or tunnel; beetle; Indian oil lamp; eyes Image A 26 Typical: Fetus; embryo Atypical: Face; reflecting repugnant emotion (pregnant woman unhappy with pregnancy) Image A 27 Typical: Human female breast; baby sucking at breast; deer’s head Atypical: Female arm being injured; marked decapitated woman Image A 28 Typical: Leg; thigh; wrist and hand Atypical: Hand from horror film Image A 29 Typical: None typical, all are “projective” Atypical: Scary face; person running; shadow of a gun Image A 30 Typical: Face; skull; Neanderthal man; monkey’s face Atypical: The rapist’s face; evil surrounded by evil; the Devil Image A 31 Typical: Two human faces, man and woman, or adult and child whispering secrets Atypical: Man and woman arguing; sad faces Typical and Atypical Responses (SIS-II B): Image B 1 Typical: Camp fire; melting ice cream Atypical: Rotting tooth; amniotic sac with embryo; heart bleeding Image B 2 Typical: Fire spreading in forest; rag doll on a stick Atypical: Ovaries; fallopian tubes and uterus; attacking animal; monster; ultrasound of vagina

Image B 3 Typical: People talking Atypical: Throat and tonsils; vagina; rectum; pelvic bones; Darth Vader’s head Image B 4 Typical: Two human faces; adult and child Atypical: A person projecting an alter personality (multiple personality disorder); mummies; person threatening someone Image B 5 Typical: Two seated human figures throwing balls; people conversing Atypical: Man and woman arguing; me (referring to self) not able to communicate with Doctor. Image B 6 Typical: Upper thighs and lower abdomen; pair of pants Atypical: Fat thighs; penis in vagina; stomach x-ray; woman’s lace panties (eroticism, typical in lesbian woman) Image B 7 Typical: Ribs; upper chest; hot water bottle Atypical: Brain; painful back; heart with arrow in or through it ; pelvis Image B 8 Typical: Nose; a man’s profile; earth Atypical: Pregnant woman; cocoon Image B 9 Typical: Lungs; kidney; penis and testicles Atypical: Woman’s reproductive organs; liver and spinal cord; gall bladder Image B 10 Typical: Bear’s face; dog; seeds Atypical: Sad dog; pregnancy; female; female reproductive organs; ears Image B 11 Typical: Lungs; two birds; flowers Atypical: Lungs distorted fighting for breath; smoker’s lungs

Image B 12 Typical: Face; man squinting hard Atypical: Evil face; expression of pain; angry face; crying face Image B 13 Typical: Colon; intestines, a question mark Atypical: Peep hole Image B 14 Typical: Pure projection, lower back; pelvis; apple Atypical: Heart; trachea and lungs Image B 15 Typical: Broken glass; paper airplanes; knives Atypical: Knives to kill someone; suicidal or homicidal imagery Image B 16 Typical: Spine; spinal cord; vertebrae Atypical: Tool for drilling; hypodermic needle; painful vertebrae Image B 17 Typical: Heart; smoking Atypical: Open vagina receptive to intercourse; a dark hole Image B 18 Typical: Spinal cord; penis in vagina Atypical: Sperm going through tunnel; two people talking; snake in a pipe Image B 19 Typical: Cell; ovum; egg; sun, heart Atypical: Broken heart (post-trauma response of rape victim); egg being fertilized (pregnancy wish); ugly spider Image B 20 Typical: Brain; exposed brain Atypical: Fetus; diseased or troubled brain

Image B 21 Typical: A gun; exploding cork; firecracker Atypical: A gun shooting someone; penis with a band around it (impotence) Image B 22 Typical: Body resting; soul leaving body; dead person Atypical: Blood spurting from chest; crime victim bleeding to death Image B 23 Typical: Spider; rib cage; heart; lung; crab Atypical: Rib cage with cancer Image B 24 Typical: Kidneys; hanging lamps Atypical: Twins (pregnancy wish); sperm; testicles; ovaries Image B 25 Typical: Pelvis of woman; hands holding glass circle Atypical: Apple; koala bear; pelvis with fire inside; desire Image B 26 Typical: Female sex organs (cervix, ovaries, uterus, vagina) Atypical: Skull; top of hammer; dog with large ears Image B 27 Typical: Fetus; embryo; child Atypical: Diseased fetus; dead baby Image B 28 Typical: Mother and child Atypical Woman holding baby close and running away; person in despair hugging ‘ self; father and child; Jesus holding and comforting someone

Image B 29 Typical: Running human figure; lame Atypical: Human figure with one leg running in fear Image B 30 Typical: Two ears, Fetus Atypical: Split brain (multiple personality disorder); lungs Image B 31 Typical: A family of two adults and two children standing together; Father Mother and two Children. Atypical: A family disintegrating; people with penises for head; four children 10. Rejection of Images ( Rej ) If the subject is unable to give any response on any of the 62 images, the response is considered as rejected. Verbalizations like spot or inkblot are not considered as responses, and are treated as Rejections. To determine the percentage of Rejection of Responses, 62 (total number of images shown) divides the total number of rejected images, then that product is multiplied by one hundred. Rejection of images shows thought blockage and an inability to think properly. 11. Pathological Scales Four pathological scales have been used (Cassell, 1980) for the evaluation of individuals. They are a) Pathologic Anatomy Scale (PAS); b) Depression (D); c) Hostility and Aggression Scale (HAS), and d) Paranoia Scale (P). Some of them are based on the work of Wayne Holtzman (1956). The scales are as follows: a) Pathological Anatomy Scale (PAS). Subjects who have personal health concerns, or who are pathologically identified with the health of others, may project responses in which the body is seen as diseased. These responses are usually related to specific regions involved in the subject’s body image, and can be appraised by evaluating the qualitative nature of the somatic material projected. The anatomical imagery is similar to that described by De Vos (1952) in Rorschach responses involving “diseased anatomy.” Body parts might be reported as red, inflamed, infected or cancerous. Organs may be sore, painful or hurting. Passages may be blocked or obstructed. Bones may be out of place or broken. It is possible to assess pathologic anatomy by summing up all such responses. All of these responses are scored under PAS. Individuals who project these responses should be further evaluated for either hypochondriacal or excessive concern about physical health. This material should be explored, clarified and assessed in the detailed inquiry and follow-up interview, since the subject may still have unresolved anxiety about this alteration in body concept. The total number of such responses is counted to form a score for PAS.

b) Depression Scale (D) A depressed subject’s emotional state can be viewed as either overt or covert. Subjects with overt feelings of depression readily admit them, and are good reporters of their own mental state. They usually exhibit nonverbal behaviors, such as sighing, weeping, downcast eyes, etc., which are consistent with the experienced affect. Subjects in a state of masked depression often conceal or deny their feelings. Frequently, they are preoccupied with their bodies hypochondriacally, and project anatomical responses, which are likely to be pathological. A depressed mood can be assessed by inkblot responses with high morbid or depressive content. The severity of these thoughts and feelings can be assessed by a study of their frequency and content quality. A four-point scale can be used to score the depressive content of inkblot imagery: Score 0: No depressive content Score 1: Slight or mild depressive content in the face of humans or animals (i.e. a sad face) Score 2: Moderate depression associated with the “inkblot’s” expression. An expression with a marked, or strong affect (e.g. a weeping person, a grief-stricken person) Score 3: Sadness or depressed affect associated with an anatomical response. For example a heavy heart, a breaking heart, or a heart with a clamp on it. Something that is suicidal, or hanging from roof, or a dead man. Individuals who are clinically depressed, but fail to recognize it, may have similar difficulty recognizing content in the SIS. In the absence of neurological disorder, a high number of Rejection responses may signify masked depression. c) Hostility and Aggression Scale ( HAS ) Hostility and Aggression can be reflected in projective responses involving physical assault or body injury (Cassell, 1977) and are scored as follows: Score 1: Animals that are predatory or hostile to humans; an implement of aggression in a dormant state; a human or an animal that is seen as fierce, aggressive, or dangerous; a hostile attitude seen in humans or animals; references to bowel function or defecation with hostile content; a knife or a snake. Score 2: Animals or humans seen as angry or in aggressive struggle, either verbal or physical; furious snakes; or abstract expressions of direct conflict or oral aggression. Score3: Homicidal scenes and/or anatomical responses involving body destruction. Subjects with histories of acting out hostile impulses have been found to project anatomical responses with murderous themes.

d) Paranoia Scale (P) A cardinal projective feature of paranoid ideation involves a heightened awareness of threatening faces that are “looking” at the individual. This may be experienced as an exaggerated sense of self-consciousness in social situations. An emphasis on the eyes” of people or animals may be present in anxiety-laden dreams. It may be clinically indicated in art therapy, with figure drawings emphasizing “eyes.” The patient may hallucinate images of such staring faces. The paranoid scale quantifies such responses. Charting of Responses - an Illustration Background Notes on Mr. X: Mr. X is 35 years old, and holds a post-graduate degree in English. He is married and the father of two children; a 4 year old daughter and a 6 month old son. He is an executive for an advertising company. He has earnings from service and agriculture, and he lives in his own house, with his family, and his parents. He belongs to the upper socio-economic class. His main complaint was of poor interpersonal relationships in the family, particularly with his mother. He has not talked with her for the last 10 years even though they are both living in the same house. He also reported having disturbed sleep, irritability and a feeling of uneasiness being indoors. In due course of time, he developed stuttering, and started keeping himself aloof from friends and relatives. During hypnotic session, he could remember when he was 10 years old. His mother and his father’s sister beat him while he was sleeping with her daughter, his cousin. His mother and aunt incorrectly suspected of sex play, which was not even in the mind of Mr. X at that age. Since then, he has developed hatred towards his mother and his aunt. He reports smooth relationships with his wife and children. Mr. X was treated for his symptoms, particularly the stuttering, in a prestigious medical institute, but could not correct his problem. The treating physician referred him for a personality assessment and hypnotic session. Mr. X was administered SIS-Video. His responses on SIS-Video are charted and shown as illustration. Charting of Responses: Each of the images has some significance; therefore, all of the responses on these images are of clinical value for qualitative content analysis. The structural meaning of each image in series A and B is given in the table of Typical and Atypical responses. The abbreviated meaning of each image is also given in the Response Profile chart below. If responses are appropriate for the images, it may be inferred that the individual has a high awareness for the region shown in the image. If the response to a particular image

is not commensurate with the meaning of the image as given in the profile, it is considered as a pathological response. Such pathological responses are indicated by a check mark, or darkening of the space. Some responses are considered to be pathological when a pathological or abnormal adjective is attached to an appropriate response. For example, on image A13, a “raised hand” is an appropriate response, but “helpless hand under distress” is a pathological response. On image B5, “two persons” in any form is an appropriate response, but “two persons involved in an argument” is a pathological percept and is marked accordingly on the Response Profile. On image A20, a “kidney” is an appropriate response, whereas “diseased kidney” is indicative of pathology, and is indicated as such in the Profile Chart. “A family consisting of father, mother and two children on image B31 is a normal response, whereas “four persons/four children/two ladies and two children fighting together, in distress or in search of some help” is indicative of some abnormality. Any response, which is clearly atypical as per the list for Typical, and Atypical responses is to be charted as such on the Response Profile. There are eleven main scoring categories for the evaluation of the protocol. These categories are more for descriptive analysis of the protocol. The first category in the evaluation of the protocol is the Total number of responses. This figure can be obtained by counting all the responses on all 62 images. In the present protocol, the Total number of responses is 59. Fifty-seven images elicited one response each, and one image, A22, elicited two responses. Images A3, A29, B1, and B14 could not stimulate any response. The total responses added to 59. Images eliciting Human responses were categorized as H, and all the H’s were counted. The response of “Ghost” on B3 was also considered as H, but since it was a deviant response, it was labeled as P. On image B6, his response was “seems like a woman suffering from venereal disease.” This response was also categorized as H, because woman is the primary response. If this response was something like, private part with venereal disease, then it could be classified as Anatomy, not even sex, but in such cases dual content is recommended. On image B22, his response was “dead woman lying on the floor.” This was also counted, as H because the woman is only dead, not mutilated. It would have been classified as anatomy if the response was “dead man mutilated.” In the present protocol, there were four responses categorized as Animal responses. These were on images A16, B10, B19, and B24. Image B24 had a response of “A strange snake-like creature with two heads, and large bulging eyes.” It was categorized as A. If the whole response was devoid of the two words snake-like, then the response would be considered as a Mythological or primitive human being and then could be categorized as H. In the present instance, the creature is snake-like, and therefore, Animal content is the safest category.

Response Profile for Quick Look Image Area of Normal Patho Image Area of Normal Patho Projection logical Projection logical A1 Pure Projection B1 Pure Projection A2 Pure Projection B2 Pure Projection A3 Pure Projection B3 Pure Projection A4 Human Body B4 Man & Woman, Two Persons A5 Human Gestalt B5 Two persons talking A6 Human/Animal B6 Lower Whole/part Gestalt abdomen/intestine A7 Women & Apple B7 Chest/internal Body A8 Male/Female B8 Nose/Earth body/Sex A9 Two persons/Man & Woman B9 Lungs/Kidney A10 Man/Woman face B10 Animals/Animal’s Face A11 Nose B11 Two Birds/Lungs A12 Ear/Fetus B12 Face A13 Hand B13 Intestine A14 Fetus B14 Apple/Pelvis A15 Stomach/Fetus/Bird B15 Knives/Broken Glass A16 Birds and Heart/Stomach B16 Spinal Cord/Vertebrae A17 Heart/Chest B17 Heart/Mouth A18 Inner body part/ B18 Penis in Vagina/Spinal Heart/Uterus Cord A19 Intestine B19 Heart/Lungs A20 Lungs/Kidney B20 Brain A21 Turtle/Bird/Babies on Side B21 A gun fired of A22 Rib cage and spine B22 Body resting/Soul leaving body/Death A23 Spinal column B23 Rib cage/Spider A24 Female pelvis/People B24 Kidney/Testicles A25 Vagina/Eye B25 Pelvis of woman A26 Fetus, Embryo B26 Female sex organ A27 Breast/Baby sucking Breast B27 Fetus, Embryo, child A28 Leg, Thigh, Limb B28 Mother and child/ Lady A29 Projection/Human Body part B29 Running man/Boy A30 Human skull, Death Symbol B30 Two ears A31 Man & woman, Two Persons B31 A family parents & children

Mr. X’s Responses to SIS-II A Responses ContentMost Typical Atypical Pathological Typical A1 Looking like an Arab in bed H T D-1 A2 It reminds me of a heart with all At AT PAS-1 arteries and veins cut A3 Rejection Rej. A4 A funny looking flower (unremarkable) T A5 A very happy, ugly person H T A6 A woman in her child’s room H T A7 Eve looking at the apple (2 response) H MT/MT A8 A naked man with a crooked smile H/M T A9 Man & woman exchanging sweet H/M MT nothings A10 A woman in the front seat of a car H/M AT D-2 and a man in the back seat. The woman is crying. A11 A couple making love H/M AT A12 An ear lobe H MT A13 Someone is asking for help with H/M MT D-1 his hand A14 A Child is sleeping on the floor on H AT a side of a statue A15 A kidney; could also be a fetus At T A16 Two fish caught on the same hook A HAS-1 A17 A woman looking at herself in the H/M T mirror, she has a big heart A18 Female genitalia Sex T A19 A diagrammatic view of the human At T body with intestines seen clearly A20 Human kidney, bladder, penis- At MT excretory system A21 A large man dancing on one foot H/M T with his children A22 1. Trachea and lungs, or At T 2. Man with a very long nose H AT A23 A vertebral column or a millipede At T A24 A monster kidnapping two children, H AT HAS-2 someone is having a bad dream A25 Vagina Sex T A26 An unborn baby curled up At T A27 Woman’s breast swollen with milk, H MT whom she feeding is not known A28 A shapely woman trapped in a H AT HAS-2 test tube (projection) A29 Rejection Rej. A30 A skeletal skull At MT A31 A boy and girl talking to each other- H/M MT something serious is the matter

Mr. X’s Responses to SIS-II B Responses ContentMost Typical Atypical Pathological Typical B1 Rejection Rej B2 Top view of a man lying on his H AT stomach B3 A ghostly face seen through a H AT P broken window B4 Husband and wife looking closely H MT at something-perhaps their child B5 Very happy scene - domestic bliss H MT between couple B6 Seems like a woman suffering H AT PAS-2 from venereal disease B7 A fly spot with a crushed insect At AT HAS-2 stuck to its side B8 A full moon and it reminds me of H T a lady wearing a funny hat holding something in her hand B9 Kidneys At MT B10 A very strange looking dog A T B11 A funny looking blouse or a jacket AT B12 A man in great anguish H AT HAS-2 B13 Looks like a cottage by the moonlight AT B14 Rejection Rej B15 Mountains being spoiled by pollution AT B16 A pregnant molecule trapped in At T a test tube B17 Dark in a power outage T B18 The penis in vagina Sex/M T B19 One of those creatures found at A T the bottom of the sea B20 Human brain At T B21 A pistol. Its barrel has burst T HAS-1 B22 A dead woman lying on the floor H T D-1 B23 Cancer At T B24 A strange snake like creature with A AT HAS-1 two heads and a large bulging eye B25 A naked woman with thighs spread H/Sex AT wide apart B26 Female genitals Sex AT B27 Embryos. One black and the other At T white B28 A very evil looking thing seems like H AT HAS-3 a cross between a man and a dog B29 Child coming home from school H/M MT B30 Two ear lobes H MT B31 A happy family H MT

CONTENT PATHOLOGICAL SCALES H = Human response PAS = Pathological Anatomy A = Animal Response D = Depression with degree At = Anatomical Response HAS = Hostility and Aggression with degree Sex = Sex Response P = Paranoid M = Movement response MT = Most Typical response T = Typical response AT = Atypical response Rej = Rejection of Images Summary of Mr. X’s Protocol: Total number of responses: Pathological Scale Human responses: PAS = Animal responses: D = Anatomical responses: HAS = Sex responses: P = Movement responses: Most typical responses: Typical responses: Atypical responses: Foot note: Most Typical, Typical, and Atypical are the form level of the responses. A response cannot be categorized as Most Typical and Atypical as well. These 3 categories are in hierarchical order, as far as the quality of form is concerned. The sum total of these responses should always be equal to Total number of responses. All the responses of the internal body parts, or mutilated whole or parts of the body were considered under the content category of Anatomy. The response on image A26, was “An unborn baby curled up” and is classified as an Anatomy response. If the response was “born baby” or only “baby” then the response category would have been H. The response on image B23 “cancer” was categorized as At (Anatomical) because it implies a diseased organ. The total number of Anatomy responses in the present protocol is 14. All the responses with explicit or implicit sexual parts of living beings, dead or alive, were categorized as Sex responses. In the present case, the total number of Sex responses was five: Images A18, A25, B18, B25, and B26. On image B25, his response was “a naked woman with thighs spread wide apart.” This response was categorized in both Human and Sex responses. All the responses indicating movement in humans or animals are counted in the Movement category. In the present protocol, the total number of Movement responses was 10: Images A8, A9, A10, A11, A13, A17, A21, A31, B18, and B29. All of the responses in Movement category are basically scored as Human, with movement as a secondary

category. The response of “crying” on card A10, “a smile” on A8, “looking at herself” on A17, and “intercourse” on B18, were all considered as Movement responses. The Most Typical responses are those given by more than 75 percent of healthy subjects on a particular image. The total number of such images is limited to 18 and is given in the text. The number of Most Typical responses in the present protocol is 15. His response on image A9 of “a man and a woman exchanging sweet nothings” is a Most Typical response, and very similar to, “two human beings/ladies” mentioned in the list of Most Typical responses. On A13 his response of, “Someone asking for help with his hand” is a Most Typical response. When a response matches qualitatively in its character and content with the response mentioned in the list of Typical responses, it is considered as a Typical response. In the present protocol the total of Typical responses is 25. Atypical responses are those of poor quality and marked by a departure from the content category of typical responses. In the present case the total number of Atypical responses are 19. On image A28 his response of, “A shapely woman trapped in a test tube” was considered as Atypical, because under Typical responses only upper or lower limbs are included. Image B11 elicited “A funny looking blouse or jacket.” It was considered as Atypical, because it markedly departed from the listed Typical response On the Pathological Scale, a response is indicative of pathological anatomy, or it is not. There are no degrees. In the present example, only two responses are indicative of pathological anatomy: eg.on A2, “...arteries and veins cut” and on B6, “Seems like a woman suffering from Venereal Disease.” The total number scored in the PAS is 2. On the Hostility and Aggression Scale, the responses judged to be indicative of hostility/ aggression are measured on 3-point scale, based on the severity of the response. In the example using the case of Mr. X, a number of responses are rated as indicative of hostility and aggression. These responses are; A16, A24, A28, B12, B21, B24 and B28. Number A8, “A naked man with a crooked smile” was not rated as HAS. Number A16, “Two fish caught on the same hook” is an idiomatic phrase indicative of aggression, but of a mild degree; therefore it is scored as HAS-1. On image A24, the response of “A monster kidnapping two children” indicates a moderate degree of hostility and aggression and was scored as HAS-2. His response for A28, “A woman trapped in a test tube” indicates a moderate degree of hostility towards women and was scored as HAS-2. Number B12, “A man in great anguish” indicates a moderate degree of aggression and was scored as HAS-2. The responses on number B21 of “A pistol” and “A snake” on B24 are of harmful objects and scored as HAS-1. Images A1, A10, A13 and B22 were scored as Depressed. The rating of the severity of the content of the responses was marked in the sample scoring protocol. The response for A1, “looking like a Arab lying on bed” was marked as D1 (the lowest degree of severity of depression). Lying in bed indicates passivity. On image A10, the response of “A woman is crying” was rated as D-2 (the moderate degree of helplessness and depression). The response for A13 “Someone asking for help with his hand” was scored

as D-1 (a lower degree of helplessness). The sum on the Depression scale is 4. On the Paranoia Scale responses are not rated in degrees. A response shows paranoia or it does not. Any response that is suggestive of suspicion is categorized as paranoid. In the present case, only one response, number B4 “Ghostly face seen through a broken window” is indicative of paranoia. Thus, on paranoia scale, the score is one. Clinical Considerations Attention should be given to signs of somatic repression. This is reflected when images with high anatomical structure are left blank or when symbolic responses are projected, disguising the somatic content. A good example is “Chinese pagoda” instead of a spinal cord on A23. Another example would be seeing a bush instead of kidneys or lungs on A20. Individuals suffering from psychogenic pain in a conversion disorder are examples of this group of respondents. In the detailed inquiry, depending on the clinical indications, specific questions may be asked to explore certain areas pertaining to the patient. For example, if the examiner wishes to explore the subject’s perception of communication with the therapist (i.e. transference material), further responses may be obtained on image B5 with this question: “If this picture represents a doctor-patient/client relationship, what do you think of their communication?” What may at first seem an abnormal image pattern may prove to be a normal variant under the added scrutiny of detailed inquiry. The response may be a defense against painful reality, a temporarily focused but generalized anxiety or an acquired or learned response from family, job, school, life experience or long-term chronic medical problems. The therapist should withhold judgment and not share it with the patient until the dynamics are clear. In classical analytic therapy, this delay is intentional and is an integral part of the treatment plan. The therapist waits until the patient has the insight, awareness and coping skills, and thus is ready to understand and process these new learning. A subject’s therapeutic readiness involves the ability to process affect-laden, repressed material, and unrealistic expectations of him/herself and others. Choosing this moment of truth, i.e. the time to share judgment, is a test of the therapist’s knowledge, understanding and judgment. Another line of inquiry concerning the determinants of SIS responses involves determining if the subject’s projected material reflects inner psychological experiences not directly recorded from past visual experience. These responses may relate to nighttime dreams, daytime fantasies, or, in psychotic individuals, visual hallucinations. For example, a woman lived in a psychologically and physically abusive marriage for years, and suffered from a post-traumatic stress disorder had responded reflecting input from her past visual reality. On A8 she saw “A man, a mean man” (depicting her ex-husband); A9 was seen as “being chased by a man”; B10 was seem as a “bruised body” (her own); and B15 was seen as “a fight with knives (her ex- husband had threatened her repeatedly with knives).”

In contrast, her response to A13 did not directly relate to her past visual reality. She saw this as a “Hand in water reaching for ground.” When her associations to this were explored in the detailed inquiry, she recalled a recent nightmare as follows: “My exhusband came and called me a mother-fucking bitch. He stabbed me in the back, over and over. Next, he took me to the water and held my head underneath. He left, but only after he thought I had drowned. After that, in the dream, I reached for the ground and pulled myself out.” SIS images are similar to images used in art therapy, in that they enable the individual to see them as an expression of externalization of the self, or the self as perceived by others. For example, there can be a perceived fusion between a child, or the self as child, and an abusive or controlling parent or authority figure. A number of artists have been interested in dreams and have attempted to represent dream imagery in their art. Leonardo Da Vinci sometimes slept holding a billiard ball in his hand, poised over metal pail. As he slept, his grasp on the ball weakened and it would fall into the pail, awakening him. Then, he would sketch what he saw in his dream. This method was used by Da Vinci to stimulate and channel his creativity. If a subject does not perceive an anatomical structure on an image, which generally elicits one (see response profile), it may be interpreted that the patient is denying physical discomfort and has low awareness. He might be having deep-rooted problems with that part of the body or organ. Emphasis or sexual avoidance of a structure may suggest conflict in that area. Emphasis on eyes, ears, or hair may suggest paranoid ideation. A higher conformity to Most Typical responses may suggest that the patient or client have group conformity in his/ her thought process. High scores on the four Pathological Scales may suggest pathology in the respective area. The greater the percentage of Atypical responses, the deeper the pathology. Rejection of Images It is equally important to understand why a person is unable to perceive on a particular image. Each image is created to depict a particular area, hence rejection of such images have lot of clinical significance. Interpretation in detail is given in chapter-7. Since these inkblots are highly structured - in the absence of any organic pathologyinability to perceive a particular blot can be highly clinically significant. It may help, in understanding his reactions to different situations presented through inkblot imagery. The avoidance of such images may further be probed to understand the unconscious process. Though responses to different images are quite relevant to understand the personality of the subject but the rejection of images may be equally relevant and may help in peeping through the inner self of the subject. Because of such relevance rejection of images have been given much importance while interpreting SIS protocol of a subject. When a person is unable to perceive images in a concrete form, it can be taken as rejection. It has been noticed that people reject images, which depict certain precept

related to their traumatised experience or underlying painful memory. For example a person having poor interpersonal relationship may reject images A7, A9, A31, B4, B5, B31, because these images project human content. Poor interpersonal relationship with spouse may also lead to rejection of images A7, A25, A27, & B18. Images like A25, A27, & B18 project more of erotic content. Since this area is disturbed because of poor relationship, people (he/she) may not feel like responding anything on these images. Similarly, it has been noticed on clinical sample of cardiac cases that persons suffering from heart problems rejects images depicting a heart - for example images A5, A18, B17, & B19. A few patients who have recovered and have accepted their clinical problems bravely do perceive ‘a heart’ on these images. It suggests that they have no fear regarding their heart as they have been properly counselled. Persons suffering from body ailments, for example Kidney problems generally reject images A20 & B9, which depict Kidneys. It has also been noticed that females traumatised sexually find it difficult to perceive image A22, A23, & B18, which generally project spinal column and male genitalia. The symbolic meaning of these images may relate to male sex organs. Since these persons have undergone traumatising experience and have unpleasant memories of the precept, they may find it difficult to see anything on these images. Even if they perceive something, often they give poor quality responses and attach a special meaning to it. For example: an educated female patient responded to images B18 as “ejaculating penis which I do not like” suggests her own suffering due to the unfortunate incident of rape and the trauma which she had for two months particularly the fear of getting pregnant. Another patient who experienced an unpleasant sexual harassment perceived “A deadly android more like a creepy insect.” The person with a broken heart (broken love affair) may see image B19 as two hearts of two persons particularly male & female are separated by social forces/ pressure. Such people may perceive two arguing male & female on A31 or a sad crying person on image A10 or B28. People in need of help from others may perceive a “helping hand” on image A13. Difficult childhood and a feeling of separation may be projected by rejection of image A6 or the inability to perceive a “teddy bear”. A feeling of separation from the mother may lead to rejection of image “B28”. It should be kept in mind that the material, which follows need to be, assimilated by the experienced clinician with the overall medical and psychiatric history data. Even certain contents from dreams and visual hallucinations may be included. There are two types of interpretation of SIS responses - Clinical and Research. Whenever a protocol is to be interpreted for clinical purposes, interpretation of the images is essential. Whenever interpretation is required for research purposes, the total number of responses, percentages for Movement responses, Animal responses, Anatomical responses, Sex responses and Rejection of images need to be determined. The number of Atypical responses, Most Typical responses and Pathological responses is equally essential.

Interpretation and Application of SIS Responses The SIS employs mainly two methods of interpretation: 1. Quantitative Analysis 2. Content Analysis 1. Quantitative Analysis: Analysis of various indices, such as total number of responses to images, number of human, anatomical, sex, and animal content; most typical, typical, atypical responses, movement and four categories of pathological responses have been created. These were established for evaluating a series of mental constructs in various normal and clinical groups. If the number of atypical responses and the rejection index, along with the total pathological score becomes elevated, then the prognosis is estimated to be more guarded. 2. Content Analysis: 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. This manual combines Medical, Psychological and Spiritual Application of SIS Images and Psychoanalytic Interpretation/ Content analysis of responses for clinical case illustrations. Medical, Psychological and Spiritual Application of the SIS Inkblots : Health professionals interested in training need not have formal credentials in psychology. While a background with any of the existing projective therapies facilitates the learning process, it is not essential. The SIS represents structured interviewing with what were originally referred to as somatic inkblots because of their high degree of anatomical resemblance. With the addition of new stimuli and modern forms of electronic presentation, these now range from those comparable in their vagueness to the Rorschach at one extreme to those at the opposite pole resembling pictures in the Thematic Apperception Test. The SIS was originally conceived in 1959 in a medical research setting at the upstate Medical Center in Syracuse, New York during a study of body image disturbances of women with hirsutism. This led to the investigation of how physical symptoms were subjectively experienced (Hollender & Cassell, 1972). To more effectively study body awareness, inkblots with a high degree of somatic structure were designed. Pathological, anatomical responses provided a scientific method for understanding the subjective experience of illness. (Cassell, 1965, 1972, 1980; Adamson et al, 1977). A number of investigators have employed the SIS in evaluating patients with medical conditions Interpretation 67

e.g. coronary artery disease (Cassell, 1984, Rathee et al, 1994) and AIDS (Gaetani et al, 1995). This projective procedure has also been employed in a number of psychiatric studies (Gaetani et al, 1995, Rathee et al, 1995, Mishra, 1996, Dwivedi et al, 1994, Cassell et al, 1996), including one involving the use of sodium pentothal (Saldanha & Dubey, 1995). It has also been shown to be useful in assessing the personality profiles of those suffering from chemical dependency problems (Singh et al, 1996,1997, Mukhopadhyay et al, 1996). A recently developed version of the SIS includes inkblots with structure resembling the traumatic events experienced by such addicted patients and their families. Apart from the above applications, there are also a number of psychological uses. After much field testing of new stimuli, non-anatomical ambiguous structure was added to the inkblot series in order to assess other issues of clinical and developmental significance. Examples follow: Image B5 depicts two people sitting down talking to each other. Much can be learned about how the patient views treatment - when for example it is suggested that the scene depict a doctor explaining about the use of antidepressant medication. Issues of future non-compliance may be identified, that may not have been evident through direct questioning.(e.g. “the man in the video would not follow the doctor’s advice”). In regard to the stimulation of images having spiritual connotations, there are also a number of applications. For example, in working with Christians, Image A3 can evoke imagery of Jesus on the cross. In terms of negative spirituality, which has been shown to be detrimental to health, other inkblots can stimulate awareness of satanic imagery. An example of one inkblot that can evoke trust and the ability to engage in psychological intimacy during nurturing medical and nursing care is image B28, which portrays “a loving mother hugging a child”. A patient, who fails to detect this embedded material, may be highly dependent and difficult to manage in a treatment setting. There may be an unconscious desire to retain the sick role in order to obtain nurturing which was never received in childhood. There are many other applications, which will be subsequently reviewed. Professionals with a variety of theoretical backgrounds have been trained in this approach. In analysing responses, while psychometric indices are available, interpretation in most clinical setting largely relies on content analysis. The diagnostician can learn much by assuming that the projected material relates either directly or symbolically to the viewer or a loved one. Sometimes what is not seen in the embedded structure for a particular inkblot may have more clinical significance than that which is actually reported. Responders suffering from conversion disorder characteristically avoid reference to anatomical structure depicting the painful region and this has been referred to as “somatic repression” (Cassell, 1980). Work with severely traumatised Interpretation

individuals suggests that the self-administered video version of the SIS can function as a type of electronic time machine. It employs beautiful mountains, mesmerising flowers and a sound track with instructions to relax so-like in hypnotherapy - the viewer may go back in time to earlier stressful periods. In these conditions the flow of projected responses may approximate imagery originally present in long forgotten nightmares. This pictorial stream provides the disturbing material in consciousness, which is eventually projected as SIS responses. At times, the viewing procedure gives much cathartic relief - a form of therapy in itself (Cassell, 1995, 1996, 2001,2002). Certain responses have special significance to physicians working with patients experiencing death anxiety (Cassell, 1979). It is also useful as a releasing trigger in the management of delayed grief reactions (Cassell and Dubey, 1996). Therapists with a religious orientation are much more effective in comforting such people than those who avoid the discussion of spirituality or who are atheists. The latter need to refer such patients to those who are experienced in working therapeutically within the systems of religious beliefs. Otherwise, it represents a form of spiritual malpractice. It is imperative to support and not undermine the faith of an individual. For example, in treating Christians, it is essential to reinforce the Easter message of hope. Because of the common use of symbolism, training with SIS can provide insights into dream interpretation. In regard to significance of dreams, Barrett (l996) summarised the diverse literature as follows: According to the poet Elias Canetti, “All the things one has forgotten scream for help in dreams.” To the ancient Egyptians they were prophecies, and in world folklore they have often marked visitations from the dead. For Freud they were expressions of “wishfulfilment” and for Jung, symbolic representations of mythical archetypes. Although there is still much disagreement about the significance and function of dreams, they seem to serve as a barometer of current mind and body states”. This latter statement has particular relevance in understanding the striking parallel between post-traumatic dreams, visual hallucinations and SIS responses. It is hypothesised that the visual cortex is episodically excited with neural impulses during sleep - much the way a computer monitor screen saver program functions. Certain of these are derived from peripheral body sensations; others from memory storage sites. The individual senses these as cerebral excitations having the vague color - movement - form characteristics of the electronic versions of the SIS inkblots. The dreamer’s psyche then projects images onto these brain sensory patterns. Many of these simply reflect residual from the stimulation received earlier in the day. What is seen has little meaning except according to Crick and Mitchison (1983) as “reverse learning” designed to remove the overloads of “neural garbage” from the brain. However, others may have considerable proprioceptive emotional and cognitive significance. For examples, when the dreamer envisions a personal scene of urinating Interpretation 69

the imagery reflects accentuated proprioceptive stimulation from a full bladder, which then may be interpreted consciously as a warning to get up and go to the bathroom. When the dreamer’s mind attempts to interpret the brain’s neural excitations, scenes of a recent stressful life event-for example having been injured in an accident-the subjective interpretation of the cerebral sensory input continues to be strongly influenced by processes of psyche projection and a number of additional factors. These include perseverating recent memory engrams of visual, auditory and pain sensations experienced at the time of the trauma. When these are correlated in time and space- by Pavlovian conditioning-with the traumatic events of a particular day in the year, the neural memory basis are laid down for subsequent anniversary reactions. Research measuring relative regional blood flow during activation of traumatic imagery suggests that the ventral anterior cingulate gyrus and right amygdala may be brain sites for such memory storage (Shin et al, 1997). For those suffering from post-traumatic stress disorder, in sleep a type of behavioural therapy induces homeostatic healing naturally in the central nervous system by the association of the traumatic imagery with a state of relaxation. With the SIS a similar desensitisation (Cassell, 1977) occurs when the stressful images are immediately followed by flowers and nature scenes designed to reduce anxiety. Guidelines for interpretation of SIS responses Anatomy responses depicting pathology may reflect fears of imaginary illness or represent subjective perceptions of actual physical disease (Adamson, Greengrass and Martin 1977, Brady, 1995). An example of the former is an apparently healthy individual who smokes heavily and consequently projects fears of developing cancer in envisioning A20 as “cancerous lungs”. Eventually, that individual might succumb to the carcinogenic effects of tobacco and then perceive “a tumour blocking breathing”. Questioning about the significance of the latter response could lead to a therapeutically meaningful exploration of the physical pain, subjective suffering and concerns about dying. Projected anatomy responses depicting “a broken heart” or “a sad face ”may symbolically signify depression and underlying suicidal ideation even though the responder may avoid reference to such painful affect upon direct questioning. The psychological defence mechanism of denial is commonly employed when the individual fears body disintegration or realises that a loved one is dying. The SIS was originally proven to be an aid in getting around denial in order to release grief in therapy. Older individuals may deny that they are preoccupied with imminent death yet project anatomical responses symbolising this anxiety (Cassell, 1980). Because of the all-pervasive nature of such concerns in the seriously ill, a number of SIS inkblots were specifically designed to facilitate therapeutic exploration of death concerns. Interpretation

Another way the SIS explores this area involves the use of cards having embedded structure capable of evoking highly threatening imagery. Certain of the blots resemble what children perceive in their dreams as “ monsters”. For example, Card 18 may suggest a demon- like monster with sharp teeth. While some clinicians may choose to ignore childhood nightmares- because they are so common - the projective use of the SIS can uncover areas of undetected trauma crying out for therapeutic processing. Rejection of SIS Images In evaluating prognosis, one of the most important SIS indices quantifies the number of rejections. Since these inkblots are highly structured- in the absence of organic brain disease- failure to respond to a particular blot can be quite revealing. It can be helpful to understand the viewer’s interpersonal interactions to observe the interaction of the human figures that are perceived in the inkblots (Lerner, 1991). The avoidance of human content may reflect a lack of interest or discomfort in relating to people. Difficulty in detecting the anatomical structure may suggest a detachment from body experiences and reduced awareness of emotionally cued body sensations. Individuals with a high somatic rejection index may manifest an inability to introspect. In regard to perceiving others they may lack empathy. Such people have considerable difficulty in focusing in on their own internal sensations associated with increase in heart rate and changes in gastric motility at times of intimate arousal. These mind- body connections begin to be laid down early in life when the infant associates the warm gastrointestinal sensations of feeding with images of the mother’s body. Failure to experience nurturing from parental figures in childhood leads to developmentally impoverished people. Just like animals that are reared without maternal contact, these fail to develop neural connections to their peripheral autonomic system. As adults they are resistant to entering close loving human relationships. Sadly enough, such concrete thinking individuals are unable to accept or express love. Sensing their lack of internal physiologic reactivity, they may report feeling, “empty or hollow inside.” Just like their inability to respond to the SIS inkblots maturely , they have great difficulty projecting positive feelings onto images of spirituality. For example, in the Christian religion , a central concept involves the trinity of the Holy Spirit, God and Jesus Christ. The first two refer to loving spirituality in the absence of visual imagery. When people think about God, they usually project human characteristics and ordinarily consider him to have a masculine sexual identity. While no one has seen Jesus in our century, there are a number of artistic representations on his physical appearance. In addition, there are religious symbols depicting his life and crucifixion (i.e., the communion bread representing his body and wine symbolising his blood). All of these images are experienced with psychological principles of projection operating. Consequently, they lend themselves to assessment with the SIS. A case history will be outlined to illustrate the emptiness within the body image that Interpretation 71

such a spiritually impoverished individual experiences. The patient came to therapy because of a life long history of severe panic attacks and depression. He had experienced his first panic attack in adolescence after waking from a dream with terrifying death images. He was highly anxious experiencing psychophysiologic cardiac symptoms (i.e. heart palpitations). These had been triggered by the nightmare and the subsequent thought that someday he would die. Since he had no belief in God, he commented, “it would be all over-there would be nothing more”. His panic attacks were mentally associated with the obsessive phase going through his mind “0h!!!no!!!no!!!no!!!”. To understand him better, certain observations about him might be helpful. He had been raised in an alcoholic dysfunctional family. Only rarely had he experienced love and then mainly at an oral phase of psychosexual development. Consistent with this he was able to identify the breast anatomical content in Image A27. However, his mother had not been especially nurturing beyond infancy, so he was unable to perceive Image B28 as “a mother hugging a child”. Consequently as he matured he distanced himself in interpersonal relationships. He also isolated himself from all internal body sensations associated with the psychophysiology of mature love. With regard to spirituality, as a youth he learned intellectually about the Christian concepts of love. However, he blocked the positive affective component from his own heart sensations. As a psychological defensive measure to isolate religious teaching, he exaggerated the human frailties of various churches. With a cynical humour he cited repeated instances of self righteous clergy claiming their members were “holy” while labelling other congregations in the community as “evil”. He took particular glee in describing his memories of “Holy Rollers” involving Christian sects that he had witnessed rolling about the floor of a tent. The notion that religious services could evoke feeling of ecstasy was beyond his scope of body consciousness. When he was in his early twenties, he married. Eventually his wife gave birth to a daughter. However, his emotional isolation continued and he was aloof from both. To fill the emptiness in the vessel image of his body, he turned to the false sense of warmth derived from psychophysiological stimulation with nicotine and alcohol. Ultimately, he became divorced. Although his daughter tried unsuccessfully to emotionally reach out to him, he defended against her attempts at intimacy by directing sarcastic humour at her. Consequently, he remained essentially alone. Later in life, as a result of heavy smoking, he developed emphysema. He also suffered from “Essential Hypertension”. As his breathing became laboured, he became more and more obsessed in the day time with ever more intense death fears. At night, more terrifying symbols threatened him in dreams. Eventually he became angry at his family physician and sought help elsewhere. When his health began to seriously deteriorate, his daughter developed a psychotic depression. She could not deal with the imminent loss of a father who was so emotionally remote. Both were atheists and resisted attempts Interpretation

to discuss spiritual concepts or referral to a pastoral counsellor. In responding to the 62-item SIS booklet, the lonely old man rejected 40 images. He avoided reference to the human and anatomical content. This paralleled his subjective blindness to positive affectual body sensations of love. For image A3 he projected his own emptiness within the body gestalt with the response “A wolf peering out of a hollow log from a fallen tree”. The symbolism is noteworthy in that in his social isolation he identifies with the cultural myth of the lone wolf. The “hollow log” symbolises how he perceives his own body with diminished positive affectual psychophysiologic sensations. The response “fallen tree” denotes his fear of his body’s imminent death. Another response symbolised how he masked his true feelings: Image A19 “It looks like a human face with a mask”. Lastly, his anger about dying was directly projected in the response for Image B10 as “an angry dog!”. No doubt his affectual disturbance played both a role in his hypertension. Apart from his pulmonary problems, he was also at higher risk for dying, in view of recent research indicating that coronary patients who survive a myocardial infarction but who are depressed, are more prone to die than non depressed ones. SIS- II/Video Death Scene When the 62 item SIS-II/Video was created, previous experience had indicated the importance of having specific inkblot structure to symbolise death and dying. Image B22 illustrated was specifically designed with this in mind. It depicts a dying person lying down having ambiguous age, sex and race characteristics. In the video version, the objects over the abdominal area move upward signifying to some “the spirit leaving the dying person’s body”. Certain clinical case studies might be of value. The first was a middle-aged woman who was in long term treatment for affective illness. During the course of this, her mother developed cerebral vascular disease and suffered from multiple strokes. Eventually she lost all her faculties including bowel control. Not only was this highly stressful to the daughter, it required extensive nursing care, since she cared for her at home without professional help. When the mother eventually died, it was a blessing but the grieving was difficult. When the SIS was administered, Image B22 was seen to represent her mother’s dying body with her spirit ascending. Afterwards, she had a healing spiritual dream: she witnessed her mother getting out of bed wearing a beautiful nightgown. Her mother expressed love and appreciation for all the care that she had received. She danced in joy showing her restored health. It was interpreted as a reassuring spiritual visitation from the mother. To interpret it as “wish fulfilment” would have totally undermined the grieving process. The dream signalled the resolution of her depression. After this message, during the day she was able to experience special psychic moments, the loving spiritual presence of her mother. Interpretation 73

Another clinically depressed Christian woman, with comparable response to Image B22 and a history of also having lost her mother to chronic illness (cancer), experienced an analogous series of healing images. These appeared during meditation when she closed her eyes in communion at church. Her experience follows: “I saw heaven-a place of gold, shimmering lights and “light”... lots of lights. I saw a banquet table surrounded with lots of food and happy people. In the midst of this joyous scene sat my mother. She was smiling and laughing with her new friends. Then I saw my mother and me both clothed in white gowns as we danced with Jesus. What was my mother saying? I believe that she wanted me to know that she’ll be there to greet me with open arms when the gates of pearl open for me one day.” After this vision, her depression rapidly resolved and she once more could feel joy. A few additional case histories might be helpful. The first concerns a teen-age youth that had been admitted to a psychiatric hospital for severe depression and suicidal behaviour. In viewing the booklet, he envisioned Image B22 as the body of his father who had shot himself five years earlier. His father had been a Vietnam veteran who had suffered from post traumatic stress disorder and alcoholism after the war. He had been highly abusive and the boy had never been able to effectively express his grief. Another example was a woman who had found her husband’s body after he had shot himself. The terrible traumatic imagery from eighteen months earlier had made her psychologically numb. In the detailed inquiry, this numbness was dissolved and she was able to process the trauma more emotionally and cognitively. Following this, she became less depressed and more in touch with her emotions. Also, themes of her deceased husband’s bleeding body faded from her post-traumatic dreams. Sometimes, in highly resistant cases, a therapist may elect to use hypnotherapy to release deeply buried or repressed grief. An example from South Africa involves a 31 year old widow who had not been able to grieve, following the murder of her husband (Savage, 1995). Traditional psychotherapies failed. Ultimately, a treatment plan was developed in which a hypnotic trance was induced during which she viewed the booklet form of the 62 Image SIS. When she viewed Image B22, she was able to release her pent-up emotions for the first time, as follows: “It is a graveyard. It lets me think of my husband’s death. It is not right that he should be there! He did not die as he should have - he was murdered and that is not right! It brings many questions to my mind: Why him? Where was God? Why did God allow it? It is only people whom I love that die!” This began the grieving process and opened the way for cognitive therapy to correct her illogical thinking. Hallucinations and Delayed Grief Reactions In certain native-American cultures-especially for males-it is not socially acceptable to show feelings of grief. These individuals are extremely reluctant to seek professional help and are ordinarily not suitable candidates for traditional therapy procedures. Adolescent natives have the highest rate of suicide in the United States. When these Interpretation

present in severe states of depression with psychotic features such as hallucinations, the beautiful nature scenes in the video version of SIS-II may be particularly useful. One Alaska native teenage youth that required psychiatric hospitalisation illustrates this phenomenon. He had been seriously playing Russian roulette with a revolver and then tried to jump off the school’s roof. In responding to Image B22, he saw his uncle’s body after it had been pulled from the river eight years earlier. The cause of the drowning was unclear. It may have been an accident related to the consumption of alcohol, or it could have been suicide. For Image B18, he saw a graveyard scene of his uncle’s body being lowered into the ground. With the emergence of this childhood death imagery into full conscious awareness, he began to cry for the first time. It also provided insights into why, in his psychotic depression, he had hallucinated his uncle calling him to join him in death. Because he projected the graveyard scene over an SIS image with phallic content, for the first time it alerted the treatment team to the possibility that his uncle had perpetrated sexual abuse. The second case to be reviewed involving hallucinations was a teen-aged girl who was admitted to a psychiatric hospital with a psychotic depression with paranoid ideation. She suffered from both suicidal and homicidal ideation. Several months earlier, a younger sister who had a series of birth defects had died at surgery. She had suffered extensively and her older sister was enraged at the surgeons and also irrationally blamed herself. She was tormented by recurring nightmares. In these, a “shadow man” threatened to kill her as punishment for allowing her little sister to die. During the day, she was also terrified by similar images of him in the form of hallucinations. In both the dreams and hallucinations, he was always dressed in black with penetrating green eyes. Emphasis on eyes has been found with the SIS to relate to paranoid tendencies (Bailey and Murstein, 1996, Savage, 1995). After viewing the 62 image SIS II, she selected Image A17 as the most threatening. She saw it to represent “two smiling fishes with a stolen heart. In the detailed inquiry, she said that the “fish” were “hurting someone just for pleasure-like the shadow man in my dream”. The parallel between her hallucinatory experiences and the SIS response continued, when she described the second most threatening image, which was A30. It resembled “a human skull waved by black”. This had a dual meaning. In the first instance, it looked like the feared “shadow man”. Secondly, it was seen to depict her sister’s “rotting head after death”. In terms of spirituality, she felt that she was beyond hope because of not saving her sister from the “evil murderous surgeons” towards whom she had homicidal thoughts. Consistent with her hopelessness, image A21 was seen as “a raven with a heart so heavy, it can not be thrown up to fly-even by angels”. Other responses relating to her clinical state follow: Image A22 “A face with a screwdriver coming out of the skull-it Interpretation 75

reminds me of killing my sister. I want to hurt or kill people just to make them feel pain and suffer the way my sister did”, Image A23 “An angry groundhog looking for revengeit brings to mind the shadow man”, Image B12 “A muscle caught by a metal clamp like the one they took from my sister’s leg”, Image B15 “Shards of glass and knives flying out of fire- I hate the doctors”, Image B16 “a tarantula pulling it prey”. In obtaining associations to this, she indicated that it reminded her of the “shadow man who is like a tarantula jerking me around... he talks to me when I am awake... he tells me that I am a murderer and killer... I need to die... I should put a knife through my heart... he wants me to leave the knife there while my body rots... he calls me by my sister’s name... he wants me to be her and to be like her in heaven, where I can have a life too”. These responses were then used as a basis for the cognitive therapy to correct her delusional thinking and to establish more appropriate reality testing. Dream Programming Another application of the video version of the SIS-II involves showing the video version at night-time prior to sleep. This can stimulate therapeutic dreams in individuals suffering from chronic depression illness dating back to losses sustained many years earlier (Cassell and Dubey, 1997, 2000, 2001). One example involves a forty-year-old woman who at age three witnessed her eighteen months old brother torn apart by an attacking pack of dogs. As a child, she was never able to process this terrible trauma. In viewing the video, for the first time in adult life she recalled long forgotten nightmares depicting the horrible traumatic memories. When this material was subsequently reported, her therapist first became aware of the need to therapeutically assist her with the loss. Releasing Repressed Satanic Memories Physicians and counsellors sometimes have to evaluate patients with histories of physical, psychological and sexual abuse. In many areas of the United States with the breakdown in the family and the high rates of drug related crimes this may involve disturbed adolescents who become attracted to satanic cults. Their memories are readily available for therapeutic processing. By contrast, it may be adults who have no conscious recollection of childhood trauma, which can in rare instances, involve organised cult activity. In extreme instances, such individuals may suffer from serious dissociative disorders such as multiple personality. Two examples will be reviewed of women who had features of this condition. Both initially came for treatment when conversion pains syndromes led to drug seeking behaviour with many doctors resulting in addiction to prescription medication. Each had repeated psychiatric hospitalisations for dangerous suicidal and homicidal ideation. There multiple personalities manifested themselves through different handwriting and strange negative behaviours for which there was total amnesia. The first case involved a middle age black woman. When she viewed the SIS video Interpretation

images, she was highly threatened by Image A10 envisioned as “Satan looking back at you through the mirror”. This projective response reflected her projecting her bad personalities on to the inkblot’s human facial structure. These personalities encompassed both threatening suicidal thoughts of self-destruction and homicidal impulses towards her husband. These had never been verbalised directly to him but revealed through the handwriting of her satanic personalities. Naturally, the notes he found got his attention, making him aware of the serious implications of her illness. The next most threatening projection was in relation to Image B19 seen to depict “the end of the world”. This is consistent with the dire predictions of many fundamental religious groups who are always predicting doomsday. She verbalised positive attributes to this vision saying that at the end “Christ would come”. Another response, which carried a high degree of disturbing affect, was given in relation to Image B15 “knives flying against someone up against the wall”. Detailed inquiry led to repressed childhood memories. When no adults were home, her older brother had chased her with a long meat knife and gestured at cutting her throat. Relating to her flashbacks and nightmares of past sexual abuse by her father, and marital rape type sex, many responses symbolised such horrible memories: Image A22 “A man’s hard penis ready to enter”, Image A24 “A vagina red and sore” image A28, “A naked man pulling off his shirt”, Image B18 “A man’s penis that wants action”, B24 “Man’s testicles”, Image A7 “Eve enticing Adam to eat the apple”. Finally, a series of responses related to the conflict in her personalities between good and evil: Image A2 “A creature from the War of The Worlds”, A18 “A heart of life surrounding an angel”, Image A31 “A man and woman yelling at each other!”, B2 “Two furry angels coming up from Hell”, Image B4 “A ghost with hollow eyes”, B12 “Someone hanging on a cross with life coming out of them”. In her intense suffering, she had the good aspects of her personalities positively identified with Jesus on the cross; Image B22 “A dead man’s soul rising to Heaven” and Image B25 “The angel of death”. With a version of the SIS called Living Images made by women artists to focus on feminine issues, certain of her responses denoted the splitting in her personality were projected as follows: “Two people becoming one trying to separate to get control again” and “Tired of the battle to separate-getting weaker”. Others picked up the pain and demonic imagery as follows: “A person being blown away-needless pain”, “the penis of the devil” and “ Satan looking into my soul”. The second woman had a similar history of incestuous trauma eventually acknowledged by her father. What she did not report was that his own father had been trained in satanic cult rituals prior to immigrating to this country from Eastern Europe. Initially, when the granddaughter viewed the video version of the SIS, many responses related to the past sexual trauma. However, one response was at the time unexplainable. Image B24 was envisioned as “a burning baby”. Two years later after hypnotherapy Interpretation 77

memories returned of participating in ritual sacrifice. The use of this SIS video facilitated the evaluation process and the ultimate therapeutic reduction in her dissociative symptoms. Stimulating Christian Imagery When the twenty card form of the SIS was first used in field trials, there was an unexpected finding concerning the projection of Christian imagery in relation to one of the SIS Inkblots. This was a card, which has anatomical content, which some responders see as depicting the female genitalia. Remarkably enough, others who avoided the sexual material saw religious symbols such as a “crucifix”, “a stained glass window” etc. One interpretation was that they employed these symbols in defending against the sexual material. This is analogous to how Christian teaching about morality may assist in preventing the acting out of socially unacceptable sexual impulses. In any case, when the new series of SIS inkblots were field tested on the Internet, another inkblot was found to evoke Christian imagery (Image A3). These were not considered to be defensive in nature, but rather a direct projection of what the inkblot actually represents. Examples follow: “Christ ascendant”, “I see Christ on the cross with his purple representing his royalty”, “Jesus Christ on the cross”, “A cross with rays coming from the point where it crosses. It’s planted in the ground. See the roots? It reminded me of Jesus’ death. I’m sad now”, “A bloodied cross such as the one that Jesus was crucified on. It is wet and dripping and it is backgrounded by the lights of Heaven”, “I see pain and suffering, but it is Jesus who is suffering for the great good of many”, “Jesus dying on the cross”, “I see the crucifixion, the roots symbolise the tree of eternal life and the yellow is the light of God shining down upon Christ” and “A cross, the blood remains, but around it are vivid colours and light-perhaps symbolic of the light offered by Christ’s sacrifice!” Other example of religious symbolism - some good and others evil - follows. “Someone just died and their soul is just emerging from their bloody body as an angel”, and “it looks like a cross with its roots in front of a stained glass window”, “An errant angel ascending to Heaven”. This looks like an angel, maybe it comes from deeper religious belief”. “A bleeding cross on a stained glass window”, “A holy woman in front of a great light who is beckoning to me with either great sadness or great joy”, “A vagina or a cross” and “an angel trying to fly through a gap”. These responses show you how some of these inkblots may be used for stimulation purposes. Examples of satanic imagery follow: “l see Satan going up to take over heaven”, “Satan: he’s eating your soul raw with a sprinkle of garlic and a dab of honey. Hmm honey, I’m only three and half years old” and “If you look at it upside down it appears to be an ugly reindeer, covered in the blood of slaughtered elves, exploding from the bowels of Hell from whence Satan has expelled him for only wounding that pesky Santa, instead of bringing back his dismembered disloyal body to the Hell he(Santa) once called Interpretation

home...(Satan speaking)” “Rudolph, how dare you offer me these petty corpses of pathetic elves. Bring me Malladeigo... I mean, Santa Clause!!”. Finally it might be of interest to note one Internet responder’s summary comments as follows: “l have read a lot of very strange ideas here. Blood and gore seems to hold a fascination for many. Flowers, birds and religion seem to be the lead. Initially I could see about nine splotches of colour smeared about in a vague symmetrical layout. Second impression was that of Christ hanging on the cross with a stained glass window effect in the background. “As far as some body’s privates, you gotta be sick!” The use of the SIS to stimulate religious imagery is a fascinating new area of investigation. Research on this could have much relevance for learning about spiritual imagery. Interested readers may review the overall responses evoked on the Internet by visiting SIS web site at http: //www.somaticinkblots.com. As another example, therapists can better learn to interpret the language of body symbolism during grieving (Cassell and Dubey, 1996, 2000). When the grief stricken individual complains about a heavy sensation in the chest (e.g. “a broken heart”), the empathetic listener may interpret this for the sadness that it represents, rather than as a symptom of physical illness. The trained listener will be able to understand it as the symbolic communication of emptiness-resulting from a loss of the joyful psychophysiologic sensations stimulated by imagery of a loved one. Given this insight, they will then be more knowledgeable about how to therapeutically introduce loving spirituality to fill the inner void in the body gestalt. For Christians, actively imaging Jesus through visual aids and meditation can effectively restore sensations of love and fill the empty heart. Adherents of other religions will achieve similar health benefits, although the imagery will necessarily be different. For example Hindus can visualise Krishna or Shiva, Buddhists the goddess Kuan Yin, Muslims the Holy city of Mecca etc. These changes in body awareness can reduce somatic suffering until imagery from dreams meditation and other spiritual experiences restore the broken love bond. This is highly important during the early stages of grieving. It is also critical at anniversaries of times of loss. (Cassell et al, 1999, 2001, 2002). Another application of the SIS involves educating trainees concerning the many parallels between what a particular individual envisions in an inkblot and what that same person projects onto spirituality. Courses can include studies using the inkblots to educate about how subjective perception operates under a variety of circumstances. For example, this can apply to understanding how different readers perceive scripture differently. They may acquire better insights into conflicts concerning the meaning of ambiguous religious writings. Those clinicians and clergy who become educated may be more adept at bringing cult members who have been brainwashed by a demonic leader back to reality. At the time of writing, the news media are currently flooded with reports about the “Heavens Gate Cult” in California. As an extreme response to celibacy, Interpretation 79

one third of the men were castrated. These fanatics committed mass suicide because their deluded leader convinced them that the Hale-Bopp comet was being followed by a space ship which would take them to heaven. Those entering the healing fields need guidance on how God gives guidance and healing through the media of dreams. When a grieving person has dream imagery of a diseased loved one appearing healthy, the therapist needs to support the faithful’s belief that this is a spiritual visitation. It is abusive for an atheist analyst to interpret this in some analytic jargon such as “wish fulfilment”. For Christians, there is also the central need to identify with imagery of Jesus, which can be stimulated by SIS viewing. Another application involves the use of the SIS as a screening procedure in assessing applicants for the health sciences and clergy. It also can be used to assist in the study of occupational stress or burnout in these highly stressful vocations. In an earlier section, it was observed that the responses given by the volunteers revealed a modest level of psychological distress. These fields require individuals who can be earthly transmitters of loving spirituality, yet they must empathetically bear the heavy burden of suffering. They need to realise their own human limitations in order to retain realistic sized egos, even when placed upon pedestals. Many of the inkblots with human characteristics can access this level of functioning. Similarly, the anatomical structure can evaluate sexuality. Prospective trainees who are vulnerable to boundary or counter transference issues can be identified early in their careers. They may be referred for personal therapy prior to acting out their problems. Boundary issues will always require special attention. Unfortunately, in some religious settings there has been much confusion between sexuality and interpersonal spiritual intimacy. Whatever one’s personal views about celibacy, prospective clerics in the Roman Catholic church have to struggle with this issue. Given rare but highly publicised sexual abuse tragedies, it would seem that traditional methods of assessment have not been especially effective in screening out perpetrators (i.e. pedophiliacs). Certain of the inkblots access erotically perverse satanic forces. This area of assessment has particular clinical relevance in the evaluation of victims of abuse. In the Living Images Series for women, a few of the inkblots were designed specifically to evaluate dissociation by presenting outlines of the body, which depict splitting. The cases reviewed represented examples of this reaction to sexual trauma. It is suggested that the SIS approaches may be used as a projective technique in association with structured interviews (Gould et al, 1996, Pelcovitz et al, 1997) to better evaluate at a multidimensional level, reactions to extreme stress. They also may be effectively employed to supplement questioned at assessing death anxiety (Cella & Tross, 1987). Commonly, clinicians encounter patients with a lesser degree of dissociative illness. These may suffer from pain in the absence of detectable physical illness. The use of the SIS may enable trained professionals to give projective data- derived consultations regarding the diagnostic significance of such “hysterical” somatic symptoms. Similarly, Interpretation

the inkblot information may be useful in identifying depressive symptoms, which are denied but symbolically projected. The latter can be of value the decision whether to use antidepressant medication. The clergy can acquire skills to better assist suffering people who withdraw from loving spirituality and destructively project evil onto themselves, their families, their physicians and other health care providers as well as religious support systems. Other applications concern the growing number of healing benefits that can come from the mesmerising aspects of the SIS video. As previously indicated the mountain and floral scenes produce an altered state of awareness. This can approximate the trance experiences that some American native religious leaders induce through religious rituals incorporating spirituality with all aspects of nature. Alaskan natives now have incredibly high rates of alcoholism, dysfunctional families and elevated morbidity and mortality scores. Some native leaders now trace these problems to the decline in their culture secondary to the deleterious impact of Christian missionaries. These wellmeaning clergy preached that it was a sin for the shamans to pass on ancient myths and legends. Native dancing was also frowned on. It is entirely possible that in the absence of their spiritual energy system, the natives may be more vulnerable to their many health problems. It is also relevant that investigators and clinicians have provided cross-cultural insights. In Japan, therapists quickly recognised the therapeutic power of electronically associating traumatic SIS imagery with natural beauty (Cassell, 1991). The mystical arts of Shinto and Buddhist religions induce spiritual effects by creating environment replete with natural and artistic beauty. Consistent with the healing power of flowers and projective technique, two videotapes have been produced; “A Walk Through the Garden of Life” and “Fantasy Flowers” to reduce anxiety prior to medical, dental and surgical procedures. Research has flourished in India where there is a vast heritage and sophistication concerning the ability of meditation to positively alter physiologic function. World-wide experience suggests that a promising area of future investigation concern exploring how that the SIS approaches can effectively bridge physical-psychological-spiritual dimensions. When appropriately integrated with modern medical and surgical therapies, this promises to play a role in enhancing the profound healing powers of spirituality. Case-1: A Case of Headache and Stammering The case of Mr. X. is described in detail in chapter-6. This detailed interpretation may help clinicians to learn the system in practice. A much shorter report is sufficient to understand the psychopathology of the patient and to communicate case information to any referring agency for their case management. Mr. X. a 35-year-old man was tested in India on June 5, 1990. He reported that he Interpretation 81

recently had a throat infection, but his main problem was stuttering. He denied having any pain, although he reported that since 1975 he had been feeling sensations of abnormal pressure in his head. Least Liked Images In reviewing his responses to the Somatic Inkblot Series, A24 was found to be the least liked. Instead of seeing material related to the female pelvis, he saw “a monster kidnapping two children - someone’s having a bad dream”. Here he avoids reference to the female pelvis, and substitutes the very threatening image material of the kidnapping of children. This material shows age regression and trauma, which are characteristics of children’s dreams. The source of symbolism needs further evaluation. It might be noted that in Rorschach procedure, he gave several responses depicting aggression. These responses were consistent with his SIS scores and his long term conflicting relationship with his mother. The second least liked image was B10. In B10, he again overlooked an image depicting female pelvic content and saw “a very strange looking dog - something frightening about it”. Again the symbolic defense that he uses in defending against the female pelvic area is highly threatening. Since this time it is a dog. It is consistent with his perception of women being threatening. Since his relationship with his wife, at least on the surface, appears relatively normal, it would seem that this reflects some degree of threat in terms of a woman’s body, which relates to his long-term conflict with his mother. The very last image that was threatening was B28. On B28, he saw “a very evil-looking thing - seems like a cross between a man and a dog”. He said that he found this threatening because the figure has “a very evil presence”. It may be recalled that the normal response here is a loving image of a woman holding her child. Again, the patient cannot see this because of his long-term conflict with his mother. He uses the symbolic defenses of a man and again, a dog. Unable to see the shape of a woman, he changes it to a man, and then instead of seeing a child, he sees a dog. The evil connotation comes through because, at some level, he does recognize the image as his mother’s. He senses and associates a negative feeling, interpreting the image as “evil”, because he did not get satisfactory nurturing from her as a child, and because of present, long standing feelings of anger towards her. The Most Liked Images B5 is the image he liked the most. He saw it as a “very happy scene”, reminding him of domestic bliss between a couple. This reflects his own happy marriage. It is remarkable, that in spite of the problems with his mother, and some deep-seated problems he has in the area of sexuality, he reports that his own marriage is okay. One wonders the validity of this report, but certainly his response to B5 is consistent with a happy and Interpretation

harmonious marital relationship. His second most favorite image was B29. He saw this “as a child coming from school”. Many individuals see this as a man running, sometimes with a leg off. He sees this in a regressive way, perhaps wishing for the happy childhood, which he never had. One does not know from his history whether his early relationship with his mother was positive or not, but he certainly wishes to regress to what he perceives as a happier existence. He saw B31 as “a very happy family”. Many individuals, in fact, do see it in this way. Perhaps it is of some note that he didn’t refer to children. It may be that his own childhood experience was not happy. Description of Images in Order A1. Was seen as “looks like an Arab lying in bed.” This is unremarkable, except that a man in bed may be going along with what was noted in the Rorschach, which was a high degree of sexual preoccupation, and it could have sexual connotations. A2. He stated, “It reminds me of a heart with all the arteries and veins cut.” This is somewhat unusual, in that it shows heightened cardiac symptoms. It is possible that in states of anger and arousal, with his irritation, he was more conscious of his heart beating. A3. He could not give a response. This was rejected, which is somewhat unusual. A4. Was seen as “ a funny-looking flower.” This is remarkable. A5. Was seen as “a very happy, though ugly person.” This shows a capacity for gestalt, and the fact that it projects happiness is consistent with his own overall happiness, in spite of his stammering. The theme of evil and ugliness does project through. The ugliness reflects his conflict at home with his mother. A6. Was seen as “a woman in her child’s room.” This is somewhat unusual, and may reflect a wish for that. It is not consistent with the fact that in B28 he avoided reference to the maternal-child content. It’s also possible that the woman in the child’s room could reflect some conflict with his mother on a sexual level, which may have occurred in childhood. This makes sense. In view of his sexual preoccupation, he has been threatened by mother-child images. A7. Was “Eve looking at the apple.” This is unremarkable, although the symbol Eve does get at the thought of sexuality, which is conflicting and may reflect certain Oedipal, issues involving himself and his mother. A8. Was seen as “a naked man with a crooked smile.” This is probably not remarkable. A9. Was seen as “a man and woman exchanging sweet nothings.” This is a good Interpretation 83

response and probably relates to his happy marital situation. A10. Was seen as “a woman in the front seat of a car, and man in the back seat. The woman is crying.” Here this is seen as being emotionally upset. It’s interesting that no further association comes to mind. What he has reported so far has reflected a happy, harmonious marriage, or it could refer back to his mother’s troubled mental state. A11. Was seen as “a couple making love.” Instead of seeing nasal content, he projected a theme of sexuality and intercourse, which is again consistent with his Rorschach material. It is not consistent with what he reports in the clinical interview, that all is well sexually in his marriage. His response shows a heightened preoccupation with sexuality. A12. Was seen as “an earlobe.” This is a normal response. A13. Was seen as “someone asking for the help with his hand.” Assuming that this is good because he probably identifies with the person asking for help. It also states his motivation to receive therapy. A14. Was seen as “a child asleep on the floor by the side of a statue.” Here, instead of picking up something related to the stomach, he introduces somewhat regressive material. This again may go back to his need for the nurturing that he never received from his mother. A15. Was seen as “a kidney, or it could also be fetus.” Both are unremarkable. A16. Was seen as “two fish caught in the same hook.” Here he avoids reference to the anatomical content in the image, and sees fish on a hook. This may be suggestive of his traumatic experience when his mother, who incorrectly suspected sexual play, beat him and his cousin. A17. “A woman looking at herself in the mirror. She has a big heart.” This shows a heightened awareness of a family image. Also his emphasis on a big heart is consistent with the heightened cardiac awareness noted in A2. Who the woman is, needs to be evaluated. Does she represent his wife, his mother, etc.? A18. “The female genitalia.” This in itself is not a remarkable response, but it is consistent with his heightened sexual imagery, as noted with the Rorschach. A19. “A diagrammatic view of the human body with intestines clearly seen.” This is a normal response. A20. Was seen as “the kidneys, bladder and penis.” This is a normal response, except that it looks like the human excretory system, which is an unusual response. It may reflect a type of perseveration from A19, or some unusual pre-occupation with his bowels. Interpretation

A21. “It looks like a very large man dancing on one foot with his children.” Probably an unremarkable response, except that if one is going to see children here, it would perhaps be more usual to see maternal imagery, but this is equivocal. A22. Was seen as “trachea and lungs - it could also be a man with a very long nose.” This is somewhat unusual. He correctly picks up the anatomical structure in the inkblot, but because the threat of the phallic material comes through displaced in the safer image of a “very long nose.” A23. Was seen as “a vertebral column or perhaps a millipede.” This is a normal response. A24. Was previously commented on. A25. Was seen as “a vagina.” A normal response. A26. Was seen as “an unborn baby curled up.” A normal response. A27. Was seen as “a woman’s breasts swollen with milk.” Whom she is feeding is not clear. Here, in a regressive fashion, he wishes for a nurturing relationship with his mother, which he never had. On Rorschach Card 1, the second response was “a breast with a nipple.” This again reflects a wish for the nurturing he presumably never had, or he wants to go back to that stage of his life. A28. Was seen as “a shapely woman trapped in a test tube.” Here, the return to the eroticism occurs. He avoids reference to the male thigh. The woman trapped in a test tube may reflect his being trapped in a test tube, or it may reflect some erotic relationship between him and his mother, where feelings have not been expressed. A29. Was seen as “ looks like an evil thing straight out of a horror film.” He is capable of having evil and horrifying thoughts and fantasies. These go back to the horror of his relationship with his mother. A30. Was seen as “a skeletal skull.” This is not remarkable. A31. Was seen as “a boy and girl talking to each other. Something serious is the matter.” In this image, he sees conflict in the relationship. It is interesting that he sees a boy and girl, instead of a man and woman. This has regressive connotations and shows his projection of conflict between males and females. B1. Was rejected. B2. Was seen as “ a top view of a man lying on his stomach.” This is unusual. The image of a man lying on stomach is seen in A20, the human excretory system. This may indicate some sexual trauma he had experienced at some time. B3. Was seen as “a ghostly face seen through a broken window.” Again, this reflects Interpretation 85

some material from the past that’s threatening to him. It may elicit some paranoid feeling he has, or he might be concerned about what the SIS is bringing up in his consciousness, and the fear that the clinician will see some of that material. B5. Was seen as “a very happy scene.” This reminds me of the domestic bliss between a couple that was commented on previously. B6. He stated that “seems like a woman suffering from venereal disease”. It continues perseveration of the theme of sexuality, through the idea of venereal disease. Whether he has been faithful to his wife or there are problems or fears in the area of his sexuality, needs to be explored. B7. Was seen as “a fly with a crushed insect stuck to his sides.” This response is consistent with the theme of aggression and violence. B8. Was seen as “a full moon.” “It reminds me of a lady wearing a funny hat holding something in her hand. It also looks like the profile of a nose.” This response is significant, because it look him awhile to ultimately see the nose. Prior to this he sees the image of a woman. Again, what is accounting for the fact that he consistently sees the image of females when typical responses are image of males? B9. Was seen as “kidneys again.” Unremarkable. B10. This was previously described. B11. Was seen as “a funny looking blouse or a jacket.” It is very unusual to see a blouse, or a jacket. He may well have some sort of feminine identification in his body image. Even though he didn’t get nuturing from his mother, he may have identified with her in an aggressor type of way. B12. “A man in anguish,” was his comment. Many people see this as such, but it certainly fits him. He is stammering because of strong inner conflict and emotional feelings that he can not express either to himself or to others. B13. “A cottage by the moonlight,” was his comment. This is unremarkable. B14. “Dark in a power outage,” was his comment. This is unremarkable. B15. “Mountains being spoiled by pollution,” was his comment. It is probably unremarkable. He doesn’t see anything aggressive, such as knives in it. He is not a person who is aware of strong aggressive feelings. He is not likely to harm himself or others. Yet, there may be lot of inner aggression that he has repressed along with his sexuality. B16. “A pregnant millipede trapped in a test tube,” was his response. This is a most unusual response. Instead of seeing the spinal content, he sees a female organism that is pregnant. His Rorschach and SIS responses have previously emphasized Interpretation

both the issue of pregnancy and the female imagery. This is his second reference to a woman being trapped in a test tube. The first was in A28. It may be that at some level, the feminine psychology within him is not being expressed. Perhaps it is trapped inside him, symbolically, in a test tube. It may be part of his stammering problem. If he could express and deal with his feminine psychology and come to terms with his mother, he would be able to speak better. B17. It is remarkable that he rejected the image even though it reflects the heart. It may be recalled that previously, on A2 and on A17, he shows some heightened cardiac awareness. Here he viewed as "something that looks like the heart" and he avoids reference to it, this reflects perceptual inhibition. This may relate to cardiac anxiety and psycho-physiological heart symptoms. Symbolically, the mental representation of his heart is associated with anxiety. B18. Was recognized as “the penis and the vagina.” This is unremarkable. B19. Was recognized as “those creatures found at the bottom of the sea.” This is unremarkable. B20. Was recognized as ”the human brain.” This is unremarkable. B21. Was recognized as “a pistol and its barrel has burst.” Seeing a pistol is a usual response. Seeing a pistol with a broken barrel picks up some concern about the effects of expressing aggressive feelings. It may be that, years earlier, he did verbalize aggressive feeling to his mother, and as a result she stopped talking to him, and this has been a major trauma to him. We also know that he was traumatized when his mother falsely accused him of early sexual behavior with a female relative. This probably was done in a very aggressive way. B22. Was recognized as “a dead woman lying on the floor.” This is a most unusual response. He may be projecting his feminine body image, or in a deeper way, it may reflect repressed homicidal feelings towards his mother. B23. He saw “ cancer.” Here, again, it is remarkable that he avoided any reference to the chest content and simply saw “cancer.” This is a pathological anatomical response. At this instance, it is not venereal disease, but cancer. He may have some feelings of depression and sadness, or hypochondriacal concerns, which are translated into fear of cancer. Of course, it may simply be that some relative may have cancer, and that is his concern. B24. He saw “a strange snake-like creature with two heads and a large bulging eye.” Here, the emphasis on eyes is quite unusual, and shows a heightened awareness of the eye. It reflects a paranoid feeling of being observed. It may be his sexual conflicts coming to the surface, as shown from his response to B2, heightened bowel awareness and a man lying on his stomach. There may also be some Interpretation 87

latent homosexual issues related to the paranoia. B25. He saw “a naked woman with thighs spread wide apart.” This continues the theme of sexuality. B26. His response “reminds me of female genitals.” This is a normal response. B27. His response “embryos. One black and the other white.” This is a normal response. B28. He viewed “A very evil looking thing, seems like a cross between a man and a dog.” This suggests his aggression towards his mother. Psychoanalytically it reveals hatred and aggression towards a woman, as generally people see “a mother with a child” on this image. B29. He saw “a child coming home from school.” This is again somewhat regressive. B30. He saw “two earlobes.” This is unremarkable. B31. He saw “a family.” This is a normal response. Interpretation of SIS Responses on Re-Administration (After 10 sessions of Hypnotherapy) : His experience of chronic pressure in the head started with a conflict with his mother. The pressure in his head reflects his own inner anguish and pain all of his built-up feelings of aggression, hurt, and sexuality in regards to his mother; all that have been in conscious awareness as a result the therapy provided by one of the author (Dubey), he became more conscious of his inner feelings and eventually his physical symptoms became less painful. Those responses, which appear to be clinically relevant, in terms of, change after 2nd testing will be noted. After 10 sessions of psychotherapy, image A4 was seen as “a woman about to hit some giant creature on the head”. Now he feels safe enough to allow himself to see an image of a woman being aggressive and safe enough to allow it to come into a higher level of consciousness. This shows that he is now handling the abusive relationship involving conflict with his mother in a more acceptable way. It is also consistent with his marked improvement. The next image shows a change in response is A10. In the re-test situation, he sees it as “a woman confessing before a priest”. The confessing woman is of interest, because it may be an expression of working through of the mother son conflict. It’s as though a type of confession has occurred between him and the therapist. Another interpretation is that if this is his mother, there has been some confession or admission to him of guilt on her part. Since therapy began, there has been minimal communication with his mother. The mother and son are now somewhat closer. A16 On re-administration was seen as “two birds singing a song“ rather than “two fish caught in the same hook”. He was able to process his traumatic experience of Interpretation

childhood, and now had normal perception on this image. A17 was seen more appropriately as “a couple of sea-horses face to face” rather than “a woman holding herself in the mirror with a big heart“. The reduction in the emphasis on the woman reflects a restoration of, and returns to, a more normal perception. As his relationship with his mother improves, he is less preoccupied with female imagery. A24 The next response, which is dramatically better, is A24. In this, he sees “three children sleeping together”. It is no longer like a bad dream. Through therapy he was able to process some of his trauma. The result is that he is less child-like and is not so pre-occupied with that type of trauma. A27 He sees “a child breast feeding”, which has helped him to come closer to his mother. A28 was seen as “a distorted female figure without head and legs”. There is still a persistence of female imagery, which is most unusual. This time, the female is no longer seen as “trapped”. The female part of him has been expressed in therapy, and he has also had a chance to talk about his conflict with his mother. The feelings are no longer trapped in a test tube. His speech is better because he doesn’t have to stammer in holding back this type of material. B1 it is interesting that for B1 he is able to give a response. Previously he was unable to do so. The response that has emerged is “a blood stain on a white handkerchief”. This is a pathological response, and it may reflect a theme of violence and aggression, but now he is more comfortable talking about them and his aggressive feelings. Previously, he was inhibited and felt like he had to repress those feelings. This is consistent with his improvement and reduction in stammering. One would also expect from his response that the feeling of pressure in his head would lessen. Clinically, this was the case. B2 Was seen as “a very untidily made keyhole”. The response here is much healthier than his original response of “a top view of a man lying on his stomach”. This second response does not have homosexual connotations. It does, however, continue the theme of paranoia, which may appear to him as “looking through a keyhole”. B3 His response to B3 is also less threatening. Instead of seeing it as “a ghostly face”, he see it as “two persons standing in a forest fire at night”. B6 Was seen as “mother and child“. This is a much healthier response than seeing “a woman with venereal disease”. Again, there has been significant improvement. B8 Was seen as “a spotlight illuminating the nose and cheeks of a man”. This is a very appropriate, sexual response. Now, he is identifying more with a masculine Interpretation 89

role, and his therapist, in a positive way. The female aspect of him has been expressed, so the preoccupation with maternal imagery is fading. The therapy has been helpful. B15 He recognized as “reminds me of war and disorder with bombers flying”. This is a reflection of his increased awareness of his aggressive impulses and feelings. This is a healthy response because he is now conscious of his feelings and verbalized some of them in therapy. This has been good. B17 This is the most interesting response. This time it reflects the pubic region of a woman. No doubt, at some level of consciousness, this was what he saw in the first viewing, but it was too threatening. Therapy has allowed this threatening material of a sexual nature to come into full conscious awareness. Of course, the response is still pathological, and still avoids reference to the heart. But, at least he is dealing with this, and is feeling more comfortable. B21 It is noteworthy that the pistol is still seen as having burst with B21. This shows consistency with the first response. B22 There is consistency in seeing a woman in B22, but this time it becomes “a woman meditating”, rather than “a dead woman lying on the floor”. He no longer has homicidal feelings towards his mother. These feelings have been resolved, and the communication is now better. B23 Was “reminds me of a crab”. This response is much more normal. He is not seeing “cancer”, because he is feeling clinically better. Some of his bad feelings have been “gotten out”, and he is no longer hypochondriacal. B26 This is seen as “a leopard or a dog belching on the back of a chair”. For a man, this is a more normal response. Not seeing the female genitals here shows that he is working through his conflict with his mother, and therefore he is less preoccupied with sexuality. B27 This was interesting. He saw “the good and evil aspects of a person”. Here he is beginning to come to grips with the good and evil within himself and his mother. He is able to love, yet see the relation as problematic. This is a good prognosis for therapy. B28 This was seen as ”a very evil looking person-more of an animal”. His aggression towards his mother has reduced considerably. B29 This was seen as “an athlete finishing in a race”. He has moved from an aggressive childlike position to one of victory in an adult. He is certainly not as regressed now. The therapy has helped him. B31 He doesn’t see a “happy family”, but he sees “a father, mother and two children”. Interpretation

He is happier with his own past, and this has been integrated as a result of therapy. Interpretation of SIS Responses on 3rd Administration (after 6 months of termination of psychotherapy) The Somatic Inkblot test was again administered (3rd time) after 6 months of termination of psychotherapy. His responses at this time were almost normal. The patient improved significantly and became symptom free. His relationship with his mother not only improved but also became very cordial and he started talking to her after many years. A few clinically significant responses are discussed below. A6 This was seen as “Playing football with Teddy.”. This is a typical response suggesting that he has resolved his childhood traumatic experiences. A8 This was viewed as “A smiling man”, symbolizing his happy mood. A12 This is seen as “waving good-bye or trying to attract attention”. This again suggests his improved interpersonal relationship, particularly with his mother. A16 This was seen as “Two birds on a branch singing a love song”. Once again the happy mood concept is projected. A24 This was perceived as “a nude female though not very clear”. This suggests a love-hate relationship, maybe with his mother, though in a very mild form. A27 This was seen as “a baby holding his mother’s breast”. This shows that psychologically he is back to his mother and is resolving the love-hate relationship. B22 This was seen as “a sleeping woman”. He has resolved his aggression and instead of seeing a dead woman, he has seen a sleeping woman. B28 This was viewed as “a mother and a daughter in tender embrace”. This suggests that he is emotionally closer to his mother. Mother and child is the most common response on this image. Clinically significant responses given by the patient at each administration are shown below to highlight the improvement in the quality of responses on the SIS images. Comparison of SIS Responses on 1st, 2nd and 3rd Testing for Quick View First testing : When sick Second testing : After 10 sessions of Hypnotherapy Third testing : Six months after termination of Psychotherapy A6 A fat woman in her child’s room. Interpretation 91

A woman in her child’s room. Playing football with Teddy. A8 A naked man with a crooked smile. A happy person. A smiling man. A10 A woman in the front seat of the car and a man in the back seat ( woman is crying ) A woman confessing before a priest. Also looks like a half veiled face. Funny looking birds perched on paper. A13 Someone asking for help with his hand. A hand asking for help. Person seems under great stress. Waving good-bye or trying to attract attention. A16 Two fish caught on the same hook. Two birds in a tree singing a song. Two birds on a branch singing a love song. A24 A monster kidnapping two children. Someone having abad dream. Three children sleeping together. Nude female though not very clear. A27 Woman’s breast swollen with milk. Whom she is feeding is not known. Child breast feeding. A baby holding his mother’s breast. A28 A shapely woman trapped in a test tube. Distorted female figure without head and legs. A female with sagging breast. B6 Seems like a woman suffering from venereal disease. Mother and child. Interpretation

An owl, one eye open and the other shut. B22 A dead woman lying on the floor. A woman meditating. A sleeping woman. B28 A very evil looking thing, seems like a cross between a man and a dog. A very evil looking person-more of an animal. A mother and a daughter in tender embrace. The case analysis suggests that Somatic Inkblot Series is a powerful projective diagnostic instrument. It works as a time machine and helps in processing repressed material. It works like a thermometer and helps in detecting the severity of emotional problems. Case 2: Police Case “Assault on Policeman ” This case involves a 34 years year old, highly intelligent man, who in his early twenties was a state trooper. While he was driving his police car alone in a very remote area, three men ambushed him. There was an extensive gun battle, during which he killed two of his attackers. However, he was wounded before back up was able to arrive and rescue him. While he was treated medically, he never had the opportunity for formal psychological treatment. Eventually, his physical wounds healed and for medical reasons he retired. Ultimately, he went to a university for training in a new field. However, for many months following recovery, he had recurrent anxiety-laden dreams, reliving the gunfight and other symptoms of Post-traumatic Stress Disorder. Eventually, many of these largely disappeared and he had only some minor physical pain periodically to remind him of his injuries. During this period, he developed classic symptoms of Panic Disorder. He experienced sudden bursts of high anxiety associated with heart pounding and the belief that he was going to die of a “heart attack”. Sometimes he had nightmares where he woke-up in terror with his heart pounding, but he could never recall the content of his most recent dreams. This is the example of how the SIS Video represents a “time machine“ by taking him back to his original trauma. When he viewed the SIS Video, he projected responses consistent with his long-forgotten “nightmares” of the shooting incident. For example, he stated that A30 represented a highly threatening image. He visualized an X-ray of the head, re-experiencing images of the forgotten trauma. The second most threatening image was B15. Here he saw “sharp thing that hurt”, replicating the bullets that had been fired through the windshield of his police car during the ambush years ago. The Interpretation 93

third most upsetting image was A3. For this he saw “a blast-hole in a police car.” He stated “I can see blood splattered on the window.” The processing of this repressed trauma represented the first step in resolving this old psychological injury. While it is better for victims of traumatic life events to process their emotional pain in the immediate hours after the trauma, there may still be powerful therapeutic value years later. The SIS Video can do much to alleviate deeply imbedded and forgotten traumatic material. Case 3: Police Case “ Witnessing an Accident.” This second case involves psychological trauma that the subject was never able to process. The subject was a State Trooper, in a remote area, who responded to an accident scene. It involved a family of four whose car was struck head on by vehicles driven by a drunk driver. This case was published in the Japanese Bulletin of Arts Therapy, (Vol. 22 No. 1, 1991). Portions of the article follows : An individual’s inner suffering can be healed by the appreciation of beauty in nature. In Alaska, it is easily possible to experience the therapeutic power of a natural setting, with no human being present for miles around. On a clear day, the sight of Mount McKinley can release intense emotions. One can sense the grandeur of the mountain and can attain perspective with regard to nature. The original native people had a more appropriate sense of values. They did not assign a mortal’s name to this magnificent mountain. With a sense of reverence, they named it Denali-meaning “the Great One.” Their medicine men incorporated nature’s healing aspects in visual art and symbolic dance rituals. Their efforts represented a primitive form of art therapy. There are many parallels between what one can experience in the great outdoors in Alaska and the healing forces stimulated by art natural setting in Japan. Japanese children are taught at an early age to appreciate the beauty of nature. They are encouraged to reproduce their visual and psychological response in a variety of art forms. One can enhance the quality of life by standing under the cherry tree, inhaling the fragrance and gazing at the blossoms. Many photographs and other works of art have been created which serve to reactivate sensory memories of such events. In some mystical way, they too can provide a revitalizing effect. Bonsai and lkebana can stimulate the senses in a similar fashion. Such work can enhance the life of the viewer, both mentally and physically. Shinto shrines provide natural settings within the urban environment, enabling one to get back in touch with healing forces. The Bhuddist religion recognizes the positive effect of flowers on the human psychic state. The lotus is a symbol of the spiritual purity. In Japanese culture, social traditions, such as bowing, ascribe deference to the spirituality of the person, who is viewed as a type of “beautiful flower,” deserving respect. In the SIS-II, we have attempted to recreate the healing power of nature as an electronic form of art therapy. Most individuals are comfortable with viewing television, and many spend considerable time watching it. In a recent book, “Television and the Quality of Interpretation

life: How Viewing shapes Everyday Experiences,” Robert Kubey and Mihaly Csikszentmihalyi (1990) reported that there is an altered state of consciousness with reduced concentration and heightened passivity. Consequently, it makes sense to employ this modern technology in the design of diagnostic and therapeutic procedures. Since the instruction are on the video tape, and the viewer is provided with a booklet containing illustration of the images under which responses may be written and the figures labeled, the examiner need not be present during the test procedures. This serves two purposes: to free up the clinician’s time, making testing more cost-effective, and to provide a viewing situation, which is analogous to dreaming in total privacy. In this solo situation, the contaminating and potentially inhibiting effect of an examiner’s presence is minimized. An additional, and clinically important, advantage is that verbal communication is totally eliminated at this stage. Pathological images, with their associated disturbing affects, will more readily emerge from repressed memories when the viewer does not have to verbalize them at the time of their return to consciousness. This manner of recording projective responses to the 62 test images of the SIS-II employs principles that experienced hypnotists have known for years. When the inhibited individual is in a hypnotic trance, if so instructed, he may be able to write answers to the hypnotist’s question that, on times, he cannot express verbally. Another approach with the SIS-II uses special video technology, whereby the television screen is embedded in a table. Using partially transparent art paper, the viewer can reproduce in color what he sees, and then label the drawing. For those in pain, this is a way to gain control over threatening imagery. The application of labels to such material can introduce intellectual defenses, which can further reduce the threat. The patient policeman was administered SIS-Video. His responses revealed that he was also suffering from a form of Post-traumatic Stress Disorder. Image A2 activated repressed, painful memories of an event that had taken place 13 years before a terrible accident. The image reminded him of a badly injured father, trapped in the wreckage, desperately trying to reach a bleeding, screaming child, who had been thrown out at the time of a head-on collision. During the detailed inquiry, his defenses collapsed, and he wept. He vividly recalled the horrible details as follows: “when I close my eyes, I can smell the heat of the pavement, and blood. Blood has a special smell!” For the first time, he was able to express his emotional anguish as a cathartic, therapeutic experience. Immediately after this was expressed, his consciousness was flooded with an additional series of memories. These concerned scenes of injured and dying children that he had witnessed when he was working with native Alaskans. There is a high rate of alcoholism among the Alaskan natives. Accidents, homicides, suicides and other acts of violence are all too common. An example of one of his painful memories is as follows: “there was this little girl lying on the table-the kitchen table. She was small-just a little thing, and she was so quietshe wasn’t moving. I had to take her from the father. He didn’t want to let her go. I had to Interpretation 95

have an autopsy. Finally, I had to pull, and say “I’m sorry!, I’m sorry!” (Expressing profound guilt and sorrow).” In follow-up psychotherapy, he recalled a series of forgotten, emotionally charged dreams dealing with trauma to children. Eventually, he acquired insight into his own background. He realized that the abandonment that he had experienced as a child by his alcoholic father had made him especially vulnerable to such traumatic events. Policeman is more likely to witness accidents exposing them to psychological trauma. Physicians and surgeons are also high risk. Those of the medical profession who tend to project high numbers of anatomical responses to the Rorschach may not just be reflecting their training and heightened familiarity with human anatomy. (Ames, Metrouz & Rodell, 1973). In addition, they may be expressing the integration of repressed pathologic anatomical images from repeated occupation of exterior. Many in such circumstances are not able to express their empathetic reactions and may tend to numb out their pain with alcohol and/or drugs. Later in life, they, like this policeman, are especially vulnerable to develop depressive symptoms. All therapists who treat traumatized victims, using art therapy techniques, should be cautioned that they should share their feeling with a colleague if their own thought content unduly reflects the visual trauma of such individuals. A potentially worthwhile therapeutic application for the SIS-II exists for art therapists who use group techniques. Individuals in distress may view the image in a group setting. The group therapist will then have the opportunity to review their pathologic responses. Sometimes it is more important clinically, in assessing the projective responses of group members suffering from hysterical conversion reaction and psychosomatic pain, for the group therapist to interpret the significance of repressed anatomical images. Another advantage of this procedure is that the use of graphic, rather than verbal techniques facilitates the crossing of language barriers. A therapist in one culture can more readily understand what is represented pictorially in another. It has been said that a picture is worth a thousand words. Also, from a therapeutic standpoint, the act of drawing and labeling images gives the troubled person a sense of mastery over the threatening material. In addition, in re-test situations, the repetitive drawing of the traumatic symbols, or the exposure to the video stimulus, in association with the healing picture of a flower after each image, can help to reduce the individual’s suffering. Certainly, this outcome occurred in the above case. The policeman reported that the repeated viewing of the SIS-II was helpful in alleviating his inner pain. Case 4: SIS in a Case of Alopecia Areata Mr. X, 29 years old, Ph. D. student, presented in July 1992 with recurrent loss of hair over scalp, arms, legs and torso for the last 13 years. His mother had a history of alopecia areata and bronchial asthma. In view of alopecia totalis, he was treated with Interpretation

prednisolone plus 300 mg once a month for four months, and had complete regrowth of hair (Sharma, 1996). Subsequently, he presented with relapse of alopecia totalis in July 1994 and gave history of stress due to conflict with Ph. D. thesis guide. He was treated with topical sensitizer diphencyprone and had complete regrowth of hair at six months and is on maintenance therapy for almost 3 years. As he narrates, his father to the extent of being physically abused frequently gave him severe beating. He perceives his father to be very authoritarian, aggressive and dominant, therefore leading to frequent quarrels between his parents, and he feels that most families in India are like his family. He is aggressive towards his brothers and sisters. 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 in the end. Initially he was withdrawn from his wife as he was feeling sexually weak. There was a 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: A3: 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 the surface 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. A5: He perceived this image as “A man crying for freedom with his body torn apart.” It brings out his inner cry and desire to get away from his broken home/family. He further confirmed this feeling during the interview and therapy session. He finds his home not worth living and wants to flee. A10: He viewed this image as “The face of 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 his mother and his inability to help her because of the dominant father. A15: He has seen “An infant pierced/stabbed by a long knife in the womb itself.” This may be indicative of his regressive phenomenon, which takes the person back in time and he feels it could have been better if he had died as a fetus. It suggests his depressive mood and that the person wants to bring out unprocessed painful situations during childhood. Imagination of stabbing in the womb itself may also be indicative of severe pain inflicted by his father during his early childhood. Interpretation 97

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 a backbone or male genital organ. The plausible explanation 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 impotence 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 a lot of pain and sufferings. A31: He perceived “a couple sharing 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 and 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 situation. Once again the theme of disturbed family life and his own withdrawal from reality as a defense mechanism has been brought out. B11: He has seen “a wig kept on the head 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 the passionate person could be the projection of himself B31: He has seen “A family with their children knitted together tightly out of some unknown certainty/fear/upheaval or resolution”, on this image. Since it is the last image 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 has seen a family with their children knitted together tightly - a painful projection. The test has worked as a time machine and has taken the person back in time to help him process the painful memories of childhood. Physical abuse, lot of uncertainty and strict discipline might be a few reasons for 98 Interpretation

such an imagination. As a whole it can be concluded that the Somatic Inkblot Test has helped the patient in projecting the painful childhood experiences, disturbed family relationship, fear of being bald and disturbed physical/emotional relationship with his wife. The test has further helped 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 a recent study from India emotional factors were blamed in unto 7 percent, in including or perpetuating alopecia (Sharma, Dawn and Kumar, 1996). These figures of 5 to 7 percent emotional factors in alopecia areata suggests patients 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 discussed in the case of Mr. X. 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. 55 percent patients revealed psychological disturbances through projection on inkblot imagery and later on owned the sufferings. Case 5: Bereavement and Hypnosis Case History: A patient whose eleven-month history of depression followed the murder of her husband on his way back from work is described. A characteristic of her symptom pattern was depression, an unwillingness to talk in the group therapy sessions and an overwhelming anxiety to the extent that she would run out of the group therapy session. She experienced persistent and disturbing nightmares but refused to discuss the content of the dreams. Four months of conventional treatment in a specialized unit did not reduce the intensity of frequency of the symptoms or suicidal ideation. In the fourth month of her admission hypnotherapy was done with dramatic results. Mrs. H. a 31-year-old widow was referred for admission to specialized unit for the treatment of depression following the murder of her husband during November 1990. She gave a four-month history of depression, loss of appetite, episodes of weeping and disturbing nightmares. She was socially withdrawn and became anxious whenever she left the house. Four months of outpatient treatment before admission did not result in any symptom relief. There was psychomotor retardation, frequent crying and suicidal ideation for three months preceding admission. One week after her husbands funeral she tried to run in front of a car in a suicide attempt but was prevented from doing so by by-standers. One week before admission she took an overdose of tablets. Mrs. H. had a sense of husband’s presence, and experienced auditory hallucinations. She would hear her husband calling her name. Her husband’s clothes were still in his cupboard and at 1700 hrs. in the evening she went to the window to wait for him to Interpretation 99

return home from work. She was intensely angry at the unknown murderers but refused to elaborate. She said their seven-year marriage was a happy one. Two children were born to the couple. Progress Notes Week One Patient refused to talk in group therapy sessions was tearful and uncooperative. At on time she mentioned that whenever she loved some one, she loses them, but refused to elaborate. Weeks Two To Five Patient remained tearful and uncooperative refused to talk in group therapy sessions. She remained actively suicidal and was not allowed to go home for weekend leave. Nightmares disturbed her sleep but the patient refused to discuss the contents of these disturbing dreams. During the fourth week, she attempted to abscond from the unit and was brought back to the ward by the nursing staff. In week five she again attempted to abscond. Week Six After six weeks hospitalization there was no reduction of symptoms. The patient was actively suicidal and refused to participate in the group therapy discussions. It was clear from the few words that she did say that Mrs. H. was intensely angry with the unknown perpetrators of her husband’s murder. Mrs. H. was placed in a grief group together with three fellow patients who had suffered losses through death. The groups were run by the author with the social worker of the unit as co-therapist. The object of the group was to provide an opportunity for mutual sharing, support and expression of anger while working towards acceptance of the loss. Week Nine After seven group therapy sessions Mrs. H. was still unable to express any anger. She did speak briefly about her difficulty at looking at her husband’s clothes. After the seventh group therapy session she took an overdose of tablets. By session ten, no reduction in the intensity of her symptoms was apparent. She was uncooperative and made another bid to abscond from the unit. The patient complained of feeling confused, helpless and had a fear of losing control. Two of the four group patients were ready for discharge and the group was disbanded. At that point on her therapy the author went on a three-week vacation. Weeks Eleven To Fifteen During this period Mrs. H. remained suicidal and very uncooperative. She refused to talk about her or the disturbing dreams. She was frequently tearful and expressed 100 Interpretation

feelings of hopelessness. She was certified in terms of section 9 of the Mental Health Act (No. 18 of 1973, Amended Act No. 3 of 1984). Certification was necessary as Mrs. H. was actively suicidal, demanded her discharge, was verbally aggressive, very tearful and attempted to abscond. Week Sixteen The author returned from leave. There was no reduction in the frequency and intensity of Mrs. H’s symptoms. A reappraisal of the situation was made. (i) The disturbing nightmares suggested repressed material that the patient found was overwhelming. (ii) The intensity and persistence of anger was a further indication of repressed material the patient had difficulty with. (iii) The fear of losing control prevented her from adequately dealing with her emotions. Intervention through Somatic Inkblot Series A decision was made to conduct hypnotherapy. Using the Somatic Inkblot Series II (SIS-II) designed by Dr. Wilfred Cassell (1980) did the initial assessment. The blot consists of 62 semi ambiguous visual stimuli in booklet form, based on specific anatomical structures. The SIS-II can be used in a variety of ways but was designed for self administration after supervised instruction. One advantage of self-administration is that it saves therapy time, reduces possibility of inhibiting responses due to presence of the therapist and serves to reduce test anxiety. The booklet can be taken home by the patient and completed in privacy in a relaxed atmosphere. Mental health professionals with training in the use of projective techniques such as human figure drawing, thematic apperception test, word association or sentence completion test will have no difficulty adapting the SIS-II to their work. The patient is requested to identify three “most liked” responses. This serves to reduce anxiety. The three “least liked” responses are examined next in the detailed inquiry. The entire series of 62 images are then scrutinized for psychopathological material or themes. The test has been found successful as therapeutic and diagnostic measure (Cassell, 1994; Dubey et. al 1993, 1994). The night after the administration of the SIS-II Mrs. H. had one of her nightmares. When she woke, she broke the frame containing the photograph of her husband and threw the furniture around in her room. Mrs. H. identified images A23, A20 and A5 as the “most liked” and images B13 and B22 as the “least liked”. The detailed inquiry was done in hypnosis. Session One The patient was introduced to the experience of hypnosis in the first session. Induction was by systematic relaxation and deepening by counting backwards from 10 to 1 with Interpretation 101

suggestion that relaxation will increase with each successive number. Mrs. H. proved to be an excellent subject and induction and deepening were readily achieved. No post hypnotic suggestion was given and no exploration was done as the patient was promised that the first session would only be used for relaxation and to allow her to experience what hypnotic induction felt like. She could decide to continue after the first session. The patient agreed to continue with the sessions. Session Two The second session was held on the following day as the patient became distressed and tearful during the night. Induction was by systematic relaxation and deepening by counting backwards from 10 to 1. The patient was then “awakened by reversing the induction procedure with the post hypnotic suggestion that she would still feel completely relaxed and calm. She was asked to focus on the first of the “least liked” images B4 and to concentrate on it. A second induction was done with deepening. She was instructed to visualize the images and to say whatever it made her feel. The following is a translation and summary of her responses. Murderers, They killed my husband. I hate them, they made me feel like this. I want to get a gun and shoot them. I am entitled to feel like this. She refused to say more even when encouraged to do so. The same procedure was followed with second “least liked” image, B13. The following is a summary and translation of her responses. It is a graveyard. It lets me think of my husband’s grave. It is not right that he should be here. He did not die as he should have, he was murdered and that is not right. It brings many questions to my mind. Why him, where was God, why did he allow it, it’s not human. If he did not love me, he would not have died. We married because we loved each other. It is only people whom I love that die. Mrs. H. then went on to give a detailed account of three major losses she had experienced that made her feel guilty. At the age of 14, a car killed her pet dog when it followed her to the shop. Family and friends could not understand her grief and told her it was only 102 Interpretation

a dog. Mrs. H. felt responsible for the dog’s death. “If it had not followed me to the shop, it would not have died.” The second loss was her boyfriend who died in a car accident on his way home after visiting her. She again felt responsible by saying that if he had not been in love with her and visited her he would have died. She did not view the body and has still not visited his grave. She was 16 years old at that time. The third loss was a girl friend that died of cancer when Mrs. H was 18 years old. “If she was not my friend she would not have died.” She did attend the funeral but did not view the body. Mrs. H was given the opportunity to “speak” to her husband and tell him how she felt and how desperately she wanted to have helped him if she could. Mrs. H was taught a self-hypnotic technique (visualization in a safe place) at the end of the session. The session lasted about one and half-hours. Session Three One week after the second session the third session was given, the same induction procedure was followed. Patient was noticeably anxious at the start of the session and 10 minutes were necessary to help her to relax. The following is a translation and summary of her responses to the third “least liked” Image B22. It is a picture of a person lying on the ground….it makes me think of something I don’t want to think about. I feel the pain … I want to forget about it. I don’t want to talk about it. It reminds me of what happened to my husband. It reminds me of my nightmares…what happened to my husband … I don’t want to talk about my nightmares. At this point Mrs. H. cried uncontrollably for about 15 to 20 minutes. At the end of that period she repeated that she did not want to see that scene again. Mrs. H. was formally given the opportunity to say “goodbye” to him. Four days after the third session she again had a nightmare, but fell asleep again after doing self-hypnosis. Behavior in the Ward after hypnosis There was an immediate change in the patient’s behavior after the third session. Her mood had lifted; she was co-operative and became a full participating member of the group. Following the third session, the patient reported that she had accepted her husband’s death and was able to give support to fellow patients in the group. Two weeks after the third hypnosis session she was discharged from the unit. She was almost completely symptom free and not suicidal. At her one-week follow up appointment Interpretation 103

she was still symptom free and reported feeling sad about her husband’s death. She had not looked at his clothes but said she knew she had to do it. Discussion The dramatic response after only three hypnotherapy sessions is consistent with reports in the literature (Fromm and Eisen , 1982; Handelman, 1984; Manthorpe, 1990). It must be clearly stated that in complicated bereavement it is not the depression but the repressed material that is treated. There are definite contradictions for the use of hypnosis for the treatment of depression and this is not recommended as a treatment for this condition. Mrs. H’s symptoms can be understood in psychodynamic terms as her struggle to relinquish or to preserve the lost object. The reality of her actual loss is greatly increased by an unconscious fantasy of having lost her internal good objects as well. Her internal world was predominated by bad objects and was in danger disintegration (Klein, 1975; Segal, 1978). The patient is unable to grieve normally because of an obstacle in normal grieving. She is unable to move in therapy because of her guilt and self blame. She believed her husband died because she loved him. An unconscious sense of guilt or a need for punishment operated to prevent relief from her suffering. Once she is freed from her self-punishment and guilt, through the use of hypnosis, she was able to take control of her life (Brabant, 1990; Epston, 1991). The use of hypnotherapy and the SIS-II enabled the therapist and the patient to identify repressed material that caused her distress. This case demonstrates the usefulness of the SIS-II and that rapid symptomatic relief in complicated bereavement can be achieved through hypnosis. Case 6: SIS in a Case of Somatic Disorder Mrs. P is a 35 years old lady, educated unto M.Phil., married to a practicing physician and having an eight years old son. She belongs to a middle class family. She had complained of frequent burning sensation in the stomach and was getting irritated quite often. She was diagnosed a case of peptic ulcer for which she was undergoing treatment. She was interested in understanding her own personality and approached the physician for help. SIS-II, booklet form, was administered and a few clinically significant responses are analyzed here for understanding how SIS Images help in processing the underlying unconscious phenomenon. A2: She has viewed this image as ‘Sita’ sharing her suffering with ‘Kush’ and facing the ‘Agni Pariksha’ (In Hindu mythology Sita is the wife of Lord Rama, who conveys her suffering to her son Kush and faces the test of fire to prove her purity to the society). This indicates her guilt feeling and unshared sufferings. She wanted to open herself to some person in her immediate vicinity, may be even the therapist. It may further indicate her poor interpersonal relationship 104 Interpretation

and disturbed family life, which she wanted to share with her eight years old son, as he is closest to her. A3: “Christ being crucified”, indicates her sad feeling and suicidal ideation. It suggests that she has a lot of depressive contents inside. A4: The feeling of her suffering and inner cry has come more directly through her response to this image, “Chekhov’s horse listening to its master’s grief, when he fails to find a human as his companion”. Where master is getting none other than a pet animal with whom he can share his grief. This projects her own sufferings and grief ridden unconscious material. A5: She has viewed this image as “Man’s effort to steal fire from the sun like ‘Prometheus’,” indicates a myth where God provided fire to man which gives light and energy. Here her response signifies that she once again wants to be warm and energetic. A6 Her response to this image “Suddenly, one day, one feels that childhood is far away and one has to complete the journey of life barefooted”, suggests her regression and takes her back in time when once again she wants to be a child, free from problems and sufferings. A8: In this image she could see, “A man in search of his identity” as she has lost her own identity. A9: Her response, “Chalte-Chalte younhee koi mil gaya tha”, (By chance someone met me on the way), takes her back in time and she remembers the time she spent with the person she had a love affair with. On interview she came out with her own story of a love affair with someone whom she wanted to marry but her family didn’t allow and unwillingly she got married to the present husband. She admits that she could not develop an internal liking for this man. They do not speak to each other frequently and to the extent of not having physical relationship for months. The same feeling has been brought by her on Image A10 also. A10 She viewed “two newly born chicken feel it’s better not to speak“. It proves that SIS images work as a time machine and takes the person back in time helping in processing the painful experiences of the past. A13: She perceived, “Remember, the icy hand of death is approaching!” Her cold feeling and suicidal ideation has been brought out. A14: She has viewed “The candle of light is burning but fails to remove the shadow of memories.” It suggests her pensive feeling towards life with a lot of uncertainty and insecurity. She is not able to ride over the unpleasant memories, which she wanted to control and remove forever. Interpretation 105

A16: She has responded, “Two birds consulting each other, where to make their nest?”. This response once again brings back the feeling of insecurity and search for a place called “home“ where she can live peacefully. The present home seems to be a broken one where she finds herself to be alone. A17: She has responded, “Two unlucky fish that have no brains yet existing”, indicates her own disturbed family life. This image generally brings out beautiful imagery of two loving birds/fishes. Instead of seeing them together she is finding them as existing without any interest. It projects her own life with her husband. A18: She has viewed, “How painful the art of creativeness is !”. She avoided seeing the commonly perceived response “heart”. She is feeling hurt and insecure in her relationship with her husband. A23: She has avoided seeing the commonly perceived response “Backbone” and has viewed “fear of breast cancer” on this image. Avoiding backbone on this image may indicate her disturbed sex life. During interview she has accepted her hatred towards her husband. “Fear of breast cancer“ may further indicate her wishful thinking to avoid physical contact with her husband by developing dreaded disease such as cancer. A25: She has viewed “An effort to provide more light as darkness prevails all over!” Avoiding seeing the female genital organ in this image has further brought out her sexual conflict. A31: She has avoided seeing male and female in this image and has responded, “Do not open your eyes. Otherwise your dreams will be shattered.” It suggests her flight from reality and adoption of life in non-realistic state. She is unable to face the reality and to manage the situation in her favor. B3: She has responded, “Hearts once broken, never heal.” Once again the broken heart concept has come back suggesting her depressive content and broken love affair. B4: Once again the depressive content is brought back by her response, “No one gets all his/her desires fulfilled.” She is not satisfied with what is provided to her, particularly the family. B5: The wishful thinking of being fortunate and having a nice time has been depicted by her response in this image, “Lucky ones! Having their full moons!” She feels, as she has not enjoyed ‘full moon’ reason being her disturbed relations with her husband. On interview, she accepted that her moon is always in cloud and she cannot imagine the pleasant feeling of a full moon. B7: She has viewed this image as, “The dancing peacock.” It suggests her ego strength and wish to lead a happy life. 106 Interpretation

B8: She has perceived “The moon during eclipse.“ This image brings back the depressive contents. Similar contents have been depicted in image B5 also. The concept of moon during eclipse, in Indian mythology suggests that the demon ‘Rahu’ is torturing the moon to take his revenge. The patient is comparing herself to the moon and perceives as if she was under the clutches of her unmanageable husband. This brings out her sufferings through her projection of the lunar eclipse. B11: She has rejected this image and could not perceive anything. Generally people perceive, lungs, two birds or flowers. She has been unable to view the commonly perceived response because of her poor interpersonal relationship with her husband. B14: She has viewed, “Let us wait for the dawn.” This indicates her ego strength and positive attitude towards the future. She is definitely hopeful of a bright future. Waiting for the dawn indicates symbolically that good time (dawn) will come after bad time (night). Such responses indicate good prognosis. B15: Her response, “Stop this violence, please“, suggests that she is not interested in violence anymore. This reflects the bad she has had in her life. B16: She has rejected this image. People generally perceive spine or vertebrae, which connote the imagery of the male sex organ. Denial of this imagery may indicate her conflicting sexual relations, which have been confirmed by the subjects. She has also avoided perceiving the common response, the spinal cord in image A23 earlier. B19: She has perceived, “When the sun begins to burn you, no shade will give you protection.” This suggests her broken home situation. She feels that outsiders can’t help if your family does not help you. Her depression has come up on the surface through this image. B22: She has responded, “Let me take rest. I have endured a lot and feel a little bit tired”, suggests her helplessness and feeling of being tired with her own family life. B31: She has perceived, “We won’t be able to grow properly if we are too many!” Being the last image of the test, it has been created in such a way that people should carry on the way back home the concept of a happy family. Since the subject is not having a happy family life, she has failed to perceive a happy family. Somatic Inkblot Series is a powerful projective instrument. It worked as a time machine and took the patient back in time where she started projecting her broken love affair. She is passing through deprived family life, constant stress, deprivation of affection with a lot of hostility and insecurity. The patient is still having a good ego strength, which Interpretation 107

has protected her from complete breakdown. She is hopeful towards a good future, which is a positive strength. SIS worked as a therapeutic tool and she was quite cheerful at the end of the test. Case 7: Therapeutic Dream Stimulation 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 over all 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, 108 Interpretation

correct her childhood erroneous belief of blaming herself. B28: Was seen as the second most threatening image. She saw this as “A ghostspooky.” 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. Dr. C: We appreciate you coming here tonight Sherry, and giving our time and a little bit about yourself. We encourage facing the inner pain. We hope this will help others understand some of the processes of grieving and what is required. Do you feel okay? Sherry: Yes I do. I feel good about it Dr. C: How did you feel about taking the Somatic Video Procedure? Can you share that? Sherry: 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 Jimmy. Dr. C: Yes, yes. Let’s start with some of the images you found most favorable. B17 were the one you found as your favorite. You saw it as “a glowing heart.” Would you care to say more about this? Sherry: 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. Dr. C: Yes, yes. Do you feel that you are now beginning to feel some grief and freeing up pain and allowing you to love with a lot more energy? Sherry: Yes, a lot! Dr. C: Could you please tell us about that? Sherry: 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, its 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. Interpretation 109

Dr. C: Before you did not feel you had the energy to love the way as you do now since you’ve been in treatment? Sherry: Not at all. Dr. C: And B31. Can you tell us what you see there and what it brings to mind? Sherry: 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. Dr. C: What was your family like when you were a little girl and all, before the terrible loss of your brother? Sherry: 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 bother 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. Dr. C: Do you wish, or did you ever wish while you were growing up for that nostalgic time that your family was complete and all? Sherry: 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. Dr. C: Yes, yes. There was one more image that I wanted you to look at. It is B29. What so you see there, please? Sherry: 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. Dr. C: And what does that bring to mind? Sherry: Um —, good health. Happiness. And probably getting out and doing something. Dr. C: So that we know that fun in Alaska and exercise is a part of the treatment of depression. Sherry: Yes that is exactly correct. Dr. C: Now, the images that really bothered you. You mentioned that A30 were highly threatening for you. Could you please tell us what you saw in A30? Sherry: 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. C: And when we talked about this earlier, you told me some other things that 110 Interpretation

were brought to mind, the devil and the pain. Sherry: With the experience I had been through before. Dr. C: Yes, could you tell us about that please? Sherry: 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. Dr. C: What was her name? Sherry: Molly. Dr. C: What was she like? Sherry: She was a real kind hearted and gentleperson. A very loving person. We were born three months apart and grew up together. Dr. C: So you were probably real close. Sherry: 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. Dr. C: And what happened? Sherry: 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. Dr. C: Do you remember how you felt when you first heard about it. Sherry: 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 Molly 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. Dr. C: Did you have images of her in your dreams for a while during that period of time? Sherry: A long time. Dr. C: What were they like? Sherry: She would come to me and she was still on the pregnant side and she would Interpretation 111

say, “Sherry, I’m okay! Not to worry, but I’m fine.” She did that several times. Dr. C: And how did you feel when you saw her in your dreams, were you sharing…? Sherry: 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 Molly, tears would come to my eyes. But it wasn’t until when Maureen (her psychotherapist) had me write a goodbye letter to her I as able to… I felt then may be I could let go of her. Dr. C: So when you were in therapy with Maureen and wrote this, what were some of the feelings you wrote in the letter? Sherry: 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. Dr. C: Did that affect your own feelings about pregnancy or having babies? Sherry: 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 Molly’s death. Dr. C: Can you share the real reason? Sherry: Probably the fear of maybe because of Molly died in child birth 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 child birth. Dr. C: And you’ve been trying to have children since then? Sherry: Yes. Dr. C: And what’s your emotional reaction, still not successful? Sherry: 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. Dr. C: You should realize that as you process grief and so on, that it is not just a central thing, but that it could affect the reproductive functioning, that you might be more receptive now, and you might connect, who knows. It’s a wonderful thought because I think you would make a great mom! Sherry: Yeah. 112 Interpretation

Dr. C: The second image that you found quite frightening were B28. Would you tell us what you see there, please? Sherry: A ghost. And it struck me as not being as being good. It struck me as being more on the bad side. Dr. C: Think of this ghost, what bad things of this ghost? Sherry: I think of Jimmy’s death and I think of Molly’s death. Dr. C: And what emotions are evoked? Sherry: Depression, everything being more on the gray side. Dr. C: And the image B1, you rated as the third most threatening image. What do you see this as? Sherry: Um — which one? Oh, anger. And I think I felt angry at Jimmy for leaving us like that. And maybe — and maybe blaming myself. Dr. C: What sense of anger did you have as a little girl for Jimmy — for his leaving you — at wandering over to the dogs, and getting killed and all? Sherry: I couldn’t understand why they had attacked him. I could never understand that. Dr. C: Could you tell us what you remember that day when you were three years old? Sherry: I remember my mother finding Jimmy 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 Jimmy was lying there on the seat I couldn’t tell you what I saw. Dr. C: So that — you always blocked out those horrible images? Sherry: Yeah. Yes, that’s for sure. And I definitely… but after my dream last night and actually seeing Jimmy with blonde hair and blue eyes — and actually seeing him, I feel relieved — real relieved about it. Dr. C: Perhaps you could tell us about the dream at this point? Sherry: 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 Jimmy 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 Jimmy and he was lying on his stomach. I wouldn’t say he was smiling, but he wasn’t sad. He just looked content. And Interpretation 113

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. Dr. C: What frightened you about this imagery in your dream? Sherry: Because I actually saw him. It was seeing Jimmy. And maybe because I didn’t see beyond the head and shoulders, I didn’t see the rest of the body. Dr. C: And why do you suppose that was terrifying? Sherry: 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. C: Because you didn’t want to see the horror, which you saw as a little girl, and this represses that. Sherry: Right, exactly. Dr. C: What were your emotions that followed then last night? Sherry: 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). Dr. C: Um, can we talk about that one for a moment? What does that bring to mind, that the floats fell off. Sherry: It brought back that the plane could not land; it could not land again when the floats fell off. Dr. C: What does that make you think of? Sherry: That it could not come back to Earth. Dr. C: And what does that bring to mind? Sherry: Jimmy. Dr. C: In what ways? Sherry: That he cannot come back to Earth! That he is gone forever. Dr. C: That is in the physical way, but not in the spiritual way — um, what is your feeling? Sherry: Um, that it is God’s way of telling me that he was probably fine. 114 Interpretation

Dr. C: Do you feel that you will see him again? Sherry: Yes I do. Dr. C: Could you share that thought? Sherry: I really do feel that I will see Jimmy again, and my friend Molly. Dr. C: That is a very comforting thought, isn’t it? Sherry: Yes. Dr. C: And there was a third dream? Sherry: 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. Dr. C: How did you feel when this train came zippin’ through the air? Sherry: 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. Dr. C: Trains are neat. What do you think your dream is trying to do with this third dream? Sherry: 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. C: 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. Sherry: Yes. Dr. C: 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. Sherry: A1 hit me as two bunny rabbits. And they look like happy bunny rabbits. Dr. C: And does that bring anything to mind? Sherry: 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. C: So this goes back to a happy childhood theme. Interpretation 115

Sherry: Yeah, oh yeah. Dr. C: Okay, A2. Sherry: 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. C: Yes, Alaska is really beautiful. Sherry: 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. C: And the sex of the person? Sherry: Ah, I never really thought of it. I would have to say a boy! Dr. C: 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. Dr. C: It’s interesting how we see images, isn’t it? Sherry: 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: A clown 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. 116 Interpretation

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. Dr. C: How do you feel seeing a baby in the womb? Sherry: I felt good and I felt a little sad. Dr. C: What’s the good part? Sherry: Birth. Um — something new happening inside a person. Dr. C: And the sad part? Sherry: Is that I do not have one. Dr. C: Yet. Sherry: 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. C: Well, we did have a volcano eruption going off here recently (laughs). Interpretation 117

Sherry: Yeah, we sure did. Dr. C: Did that depress you? Sherry: Yeah it did. Dr. C: What was your reaction to it? Sherry: 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. Dr. C: Gets your attention quick, doesn’t it? Sherry: 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. C: 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. B4: “A side view and front view of a face—kind of together.” B5: Was “two people sitting down and they looked like they were throwing bottles between each other.” Which to me was that they were having fun. Dr. C: You’re going to have more fun as you process this grief. Sherry: Oh yeah, a lot more fun (smiles). Dr. C: 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. 118 Interpretation

Interpretation 119 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. B15: Was a child’s finger-painting. Dr. C: The face in the bottle, does that bring anything to mind? Sherry: It was like something was trying to appear, but it was not quite clear. Which would bring to mind the image of Jimmy, but not quite clear. Dr. C: Yes, previously viewing the SIS, did you have many dreams about him? Sherry: No, not that I could remember. B16 reminded me of an African with a mask on. B17: Which was my favorite, was the glowing heart. 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. C: It sounds like you had a lot of fun when you were a little girl. Sherry: Oh yes, we did. B22 : Reminded me of a person lying down with bubbles coming out of him. Dr. C: We had talked about that one a little bit ago. Would you like to expand on that image a little more? Sherry: Yes, that one was like the life leaving a person I think. It’s… Dr. C: What does that bring to mind? Sherry: Yes, of Jimmy dying, is what it brings to mind. Dr. C: How does that make you feel when you think of that? Sherry: Sad, very sad about it. Dr. C: It sounds like you had a good cry last night? Sherry: I did (laughs). Dr. C: It helps, doesn’t it?

120 Interpretation Sherry: I felt really relieved. Its — 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. Dr. C: What was the emotion? Sherry: Togetherness and happiness. Dr. C: Yes. Sherry: Yes, very, very much so. Dr. C: Thank you. Sherry: (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. Case 8 : The SIS and Hypno-Therapy in a Case of Marital Problems “What is learned and remembered is dependent on one’s psychological state at the time of the experience” (Rossi, 1986, p.47). 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. The Case presentation illustrates the use of the SIS as a projective technique and an adjunct to hypnosis, to help patient 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

Interpretation 121 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 patient described is a woman with marital problems, an anorectic child and a woman with chronic anxiety. Once the memory was accessed and reframed, she showed a dramatic improvement in her condition. 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 hypno-therapy 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 hypno-therapy the patient showed no signs of improving. She was referred to the author for hypno-therapy. 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. A6 Looks like a teddy bear sitting here could either be legs. Also reminds me almost like sperm going somewhere. Could also be me keeping myself closed. 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 is always wanting to listen. A13 A hand and it looks like some hand of a plant or something. Saying stop right there. Like its telling you if you go any further it might be dangerous. Could

122 Interpretation also be a flame or something that is in the sea, something like that? 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, and development-taking place. B1 Head of a baby, flames, and 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. Therapist : What is she sad about ? Patient : I do not know. May be she wanted something she was not allowed to get. Therapist : What do you think it could have been ? 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 plaits 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

Interpretation 123 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 grand father 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. Therapist : What does that make you think of ? Patient : People not saying her true feelings, just smiling, a smile on her face. I am always smiling don’t let anyone know. Therapist : Why did you get married ? 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, may be I did not forgive XX (She mentioned her own name) for what she did. At this 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

124 Interpretation 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. Discussion The case demonstrates the usefulness of the SIS in identifying deep-seated conflicts which patient is 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 It could be argued that the problems would have eventually been identified but at considerable emotional cost to the patients. The case history has demonstrated the usefulness of the SIS images to identifying deep-seated conflicts.

Case 9 : SIS in a Case of Examination Anxiety 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 SIS journal. This presentation represents a longitudinal case history study of eight years comparing the diagnostic and therapeutic utility of inkblot images. [t 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 Interpretation 125

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 in this instance, 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 his improved 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 A13 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 126 Interpretation

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 images of 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 31A to represent “Two lovers kissing”. Similarly, he envisioned 17B 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 22B 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 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, somehow the great creativity inherent in Herman’s blots have been forgotten by modern professionals who over utilize reductionism scoring in cult like training seminars. Interpretation 127

Table 24 Comparison of Rorschach Responses on 1st, 2nd, 3rd and 4th Testing: First testing : When sick Second testing : After 10 sessions of Hypnotherapy Third testing : Six months after termination of Psychotherapy Card 1st Testing 2nd Testing 3rd Testing 4th Testing No. I Bat Bat Bat Bat II Faces of two persons Two persons Two kids Two persons clapping like clapping. clapping. 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 Two children playing Two kids standing Two children on a Rock on something. playing VIII Two animals climbing Two animals like Two animals on Two animals wolf going up. wolf going up a rock climbing climbing IX Arial view of a valley Rejected Web’s type Two animals X Various animals- Various animals- Various animals- Various animals- Spider, Peacock, Rats Spider, Peacock, Rats Peacock, Spider, Spider, Peacock, Fish Rats Table 25 Comparison of a Few Significant SIS-I Responses on 1st, 2nd, 3rd and 4th Testing: Card 1st Testing 2nd Testing 3rd Testing 4th Testing No. Two hens sitting 1.Two hens 1. Two hens 1. Two hens 2. head of a person 2. head of a 2. head of person person 1. Bat As some one has Mother & two Mother & two 2. Two children been killed babies babies playing Two penguin Two children Two children Two children playing playing joining hands playing Insect with mouth Insect like Clown Clown beatles Face of ghost 1. Bat Man's face Face of a 2. Eyes, mouth face person of some one Rejected Face of a person Face of some Face of a thing person 128 Interpretation

Table 26 Comparison of a Few Significant SIS-Video Responses on 1st, 2nd, 3rd and 4th Testing: Card 1st Testing 2nd Testing 3rd Testing 4th Testing No. A 3 Plant uprooted. Roots of a plant Roots of a plant Lovely flower with with branches colored root A 13 Looking like fungi Hand surrounded Hand surrounded Hand of person algae by fire by plant clapping A14 Picture on a wall Liver Human Stomach Energy being sent from a person A18 Smoke ring Lava/Smoke Volcano Cloud from Bright gases Volcano ejected by Volcano A 21 Looking like a bat Two small children Two children Hand of a person with bat playing around who is clapping their mother A24 Rejected Forest with tree Pond in a Forest Mother and baby A31 Faces of man Man and Women Man and women’s Two lovers and women face kissing B4 A girl seeing her Two faces Two male and Girl and boy sitting face in a mirror female faces in a park B17 Looking like Heart beating Bright flower with Heart beating on volcano crater petals valentine day B18 Rocket going up Penis Penis of a person Graphic artist in war working on Epic B22 A person sleeping Dead body soul Person laying Man sleeping and and thinking of going up down and thinkthinking of Shen some thing ing he is dead & Ming soul is going up B23 Depression created Spider with legs Spider with legs Bright color in a by a bomb shop B28 A girl embracing her Women embracing A girl clinging her Mother and mother her child mother daughter B 31 Couple with children Man women with Couple with their Happy family their children two children boy and girl Most educated people associate the name Rorschach to the notion of inkblot testing. 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 Interpretation 129

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 can not 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 130 Interpretation

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. What ever the professional discipline of the clinician, their should be a rich background of depth psychology, psychoanalysis and psycho-synthesis in interpreting the direct and symbolic meaning of projected responses. In fact, symbol 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. Case 10: SIS in Sexually Assaulted Female Miss X, 27 years, unmarried, Las Graduate, practicing as attorney, belonging to high middle class family, has 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. Intervention of a few responses found to be quite relevant has been given for understanding the psychopathology of the case. A few responses on SIS-Video given by Miss X is discussed ahead : A1 On this image 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 of a man rather than of women may reflect her sexual identification partially identified with that of her perpetuator. A3 Many people in viewing A3 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 by seeing “My soul when will it become free”. A5 She viewed “A Lady who is all heart celebrating along” on A5 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 who is critical and non supporting. Her depression is abnormally high and she has given lot many responses depicting depression. A6 “A sad teddy bear” on A6 brings back the theme of sadness or depression Interpretation 131

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 child like fashion in a teddy bear. A10 On this image “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” on this image. 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 acknowledge tot he 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” on A12. 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 fell 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 she 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. The hand symbolizes that part of herself that “I won’t on A11, will not allow her self to trust the therapy it would be necessary to interpret the symbolic significance of this response in terms of transference. Lastly the reference to “giving up” continues the depressive feelings of her helplessness A14 She saw “A dry flower” on this image. Here rather than recognizing the anatomical structure, she projects her self image as being dead inside. A18 On this image 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 fantasize running away from her home and escaping from her problems. 132 Interpretation

A23 She saw “Looking like a deadly ardroid, resembles a creepy centipede (scary feeling)” on this image. 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 fallen 4 years earlier injuring her tail bone and causing considerable pain. The other relate to phallic connotation of this particular image. While both hypothesis 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 a 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. A31 On this image 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 in 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 her self in therapy looking at her own self -image. The fact that she sees her reflection as “not sad” represents the psychological defense mechanism of denial. The introduction of the idea that the woman is confused symbolizes her own confusion and cognitive disarray. B3 “Two people sitting inside a womb overlooking an alter of fire. Here fire signifies life (feeling of wonder)” was her response on this image. Seeing 2 people inside the womb continues 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 inner context. If she is willing to share her pain during therapy, there is hopeful recovery. B6 She saw “ A half statue girdle downwards with some infection around the girdle (Feeling of depression)” on this image. Here she partially picks up the correct anatomical structure referring to the lower abdomen and thigh. However, because of her 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 injured genitalia. The facts that this image accentuate her feeling of depression in responding to the image indicates that she is grieving the loss of her virginity and body boundary intactness. The assault on a child’s body is 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 Interpretation 133

on A31. The other explanation could be her repeated infection in her pelvic region for which she has taken treatment. B12 On this image she viewed “A parrot hanging upside down trying to fly away”. Here again she totally represses the real structure of the image, which denotes some man’s facial area and nose. The fact that the bird is seeing upside down trying to fly away directly 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 this image. 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 on 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 affection. 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 here me?” on B30, Here like in A12, she directly asks the therapist if her inner cry will be heard and responded to therapeutically. It is important from the point of view of establishing the early 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. 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 this case study, it was the obvious percepts to unstructured stimuli which helped the subject to project her inner cry. Case 11 : The Use of the SIS and Rorschach in Releasing Somatised Grief 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 (VonFranz, 134 Interpretation

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 hypnogogic 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 earlier, resulting in depression and required antidepressant medication earlier . 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 and interview with the authors follows: Dr. C: I appreciate your coming here today and could you tell us a little bit about the extent of your depression and how it relates to your father’s death and so on ? Mrs X: I 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. Dr. C: What was his sickness? Could you tell us? Mrs 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 Alaska in June of 83 and it just wasn’t my father. Dr. C: Yeah. Mrs X: He had changed quite a bit from the chemotherapy and that. Dr. C: What were the changes you saw in your father with this cancer and how did that impact you at the time? Mrs 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. Dr. C: How old was he at the time ? Mrs X: He was 56. Dr. C: So that must have been hard for you to see that? Interpretation 135

Mrs 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. Dr. C: Could you tell us if you had images of your dad in dreams? Mrs X: Yes, he looked like my father and not like this person that I saw when we came back. Dr. C: How would you feel when you saw your father the way he used to be in your dreams? Mrs X: Secure. Dr. C: Yeah, you loved your dad. And then when you’d wake up how would you feel when you realized it was just a dream? Mrs 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. Dr. C: Did you ever have visual experiences or sense his presence in the waking state? Mrs 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. Dr. C: And what emotions would you feel at the time? Mrs. 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.C: 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 was going to have Dr. Dubey go over the results of the Rorschach with certain of the cards so I’d appreciate if you would share with him as well, O.K. Thank you. Dr. D: I would be interested to know a little more about these images that you have already seen. You have responded on card #2 something like “Cancer cells...” Mrs. X: It’s just. Dr. D: Would you tell something more about it? Mrs. X: It just reminds me of the cancer cells eating him up inside and him having a hard time not being able to speak because of the strokes. Dr.D: I am sorry. Can you think of something more on this card? Mrs. X: Just the cancer and the blood. Wondering where the blood went because my father was cremated. 136 Interpretation

Dr.D: On card #8 you perceived “there is an arm in the center and there are two persons grabbing and pulling me down”. Can you tell a little more about this? Mrs. 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. Dr. D: Yes. Of the two persons, one is your mother and the other one your son, is that so? And are they helping each other? Mrs. 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. Dr. D: May be it reminds you that at this juncture when you really needed her help she was not that helpful? Mrs. X: She thinks it’s all in my head. Dr. D: Take care. On card #9 your response was “A person hiding behind and feeling ashamed like me”. What makes you feel like that? What makes you feel ashamed? Mrs. 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..... Dr. D: Please take care. It was a painful disease and why you feel responsible for his death? Why you blame yourself? Mrs. 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 mistake. Mrs. 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: O.K. This is card #10. And you said, “This is an explosion and there is something coming out of mind.” What makes you to think so? Mrs. 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 Interpretation 137

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, a release of tension, how is that? Mrs. X: By not keeping it in anymore. Finally by 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. Dr. D: Is that a feeling of helplessness? Mrs. X: Yes. Dr. D: Now let us review your response on the SIS-I. You have selected card #20 as the most threatening image to you. And here you have given a response, "It’s like death coming to me. May hurt me". So please elaborate a little more. Mrs. 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. Dr. D: Are you still so much afraid that it might come at any time and it may hurt you? Please tell about this. Mrs. 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. Dr. D: On card #12 you have seen blood. May be the card is of red color and probably this red color reminds you of blood. Would you say a little more about this? Mrs. 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. Dr.D: How that blood has come? Mrs. X: Through surgery and death. Dr.D: Surgery! What kind of surgery? Mrs. X: Surgeries that I’ve had and death of my father. Dr. D: Please take care. I am going to show you another card, card #18 of SIS. And here you have said “the gate of hell”. Would you tell about this gate of hell? Mrs. 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. 138 Interpretation

Dr.D: It’s very painful. Mrs. X: It’s scary. Dr.D: Yeah. Is it the whole thing or just the eyes watching you and waiting for you? Mrs. X: It’s the mouth opening up and as I go through closing in on me. Dr. D: Does it still remind about your father? Mrs. X: I’m afraid that’s where my father is. Dr. D : On card #5, you have said “pain” . What sort of pain is that? Mrs. X : It’s the pain eating inside. The pain my father had felt. The pain that I feel and when I need him he is not there. Dr. D: Can you imagine this red spot inside? Mrs. X: It’s like a disease. Dr. D: What sort of disease is that? Mrs. X: Cancer. Dr. D: Yeah. Mrs. 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. Dr. D: Can you relate these red spots? Do they look like something to you? Mrs. X: Right now they just look like little people that are trying to take him over. They want to get in and spread more. Dr. D: Can you think of who they might be? Mrs. X: Just a disease. Dr. D: It’s really very painful to think of your father and his disease. This is card #6 of SIS. Right here you have said “a child in tension.” Can you tell us more about this child? Mrs. 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 does not understand it because he had always had the mother’s attention. Dr.D: Does this child remind you of anything? Mrs. X: My son. Dr.D: Yeah. Interpretation 139

Mrs. 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. Dr. D: Just to save him? Mrs. X: Yeah, and I shouldn’t have. I should know. I just wanted Kevin to grow up and be loved. You know he deserves that. Dr.D: Yeah, and now the last card. This is #19 of the SIS and here you saw “something is dying”. What is that? Would you like to elaborate? Mrs. 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. Dr. D: Take care.Now I wish to discuss your responses on a few SIS Video images. On image A2 you have said “a bad life with lots of uncertainty”. Would you like to tell about this? Mrs. 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 some one else. Dr. D: Oh? Mrs. X: 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 have said that it’s beautiful flower but later on you said that it’s a flower with roots and an insect is eating the roots. Mrs. X: That’s what it looked like. Dr. D : Can you elaborate little more? Mrs. X: It’s just that there is somethings that is beautiful and some people that want to destroy. 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”. What’s that? Mrs. X: My father reaching from the pits of hell. My father wasn’t a bad man but he had problems and ......... 140 Interpretation

Dr. D: Is that his hand in need of help? Mrs. X: Reaching out for somebody to help him. Dr. D: Do you think that he got the help he needed? Mrs. X: Sometimes. Dr.D: Yeah. Mrs. X: Then when I think back on some of the things I did, he didn’t. Dr.D: So the help and support he should have been given, he didn’t. I’m sorry. Let’s proceed further on image #A21. Mrs. X: Right here. Dr.D: On A21 you have seen “a man is being torn apart by sickness”. Who is that man? Mrs. X: My father being torn apart by cancer. Dr. D: Your father? Mrs. X: Being eaten up with cancer. Dr.D: You perceived on image A26 “baby” trapped in a ball and that baby is not able to come out”. Will you describe about this ? Mrs. 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. Mrs. 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 said “cancer eating up all good cells”. So again you are thinking..... Mrs. X: My father. Dr. D: Let’s proceed to image #B3. You perceive people, man and woman sitting in a house on fire”. How is this? Mrs. 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. Dr. D: Don’t they realize? Mrs. X: What’s going on. It’s like they’re not there. Dr. D: Um huh. Will they be able to save themselves? Mrs. X: I feel that way sometimes. Interpretation 141

Dr.D: And on image 9B you have seen “bad lungs”. What do you mean by bad lungs? Mrs. 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: Sorry. Mrs. X: I don’t want to die of cancer. I don’t want to go like my father did. Dr. D: Proceed further to image B20. You saw “brain covered by bad cells”. What is that? Mrs. X: Cancer cells in the brain. Dr. D: Last image on SIS video B22, you saw “a man lying down with a bad pain”. What is that? Mrs. X: Bad pain. Fire in his stomach. It just looked like there that his stomach was on fire. Dr. D: Can you tell more about this? Mrs.X: It was like fire, you know the smoke and uh the pain and my father got hurt very badly in the hips and around there. Dr.D: You have not listed the three images which you liked the least. May be you weren’t able to select 3 images. Mrs. 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: But it helped you in releasing lots of emotions, pent up tensions and feelings making you to feel sad, I guess. Mrs.X: Well they are. Dr.D: How do you feel after taking the test? Mrs. X: Drained. Sometimes better. And then sometimes it just brings up memories of watching my father die in the hospital. We didn’t leave his side until the end. Mrs. X: Because my husband was stationed in the states. And I was in and we found out we were coming back. Just before we left I was in an P I ward in Virginia and they were trying to help me. They were trying to help me get to, I guess, get ready for what I was going to see. It was a really big change and Dr.D: It’s very painful. Mrs. X: I guess nobody could prepare you for that. But then when he went in the 142 Interpretation

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 agony with me. We’ll be meeting again. Dr. C: Dr. Dubey thank you very much for the sensitive and probing interview with Mrs. X. It seems we have a powerful approach with the combination of the Rorschach and the SIS (Card Form and then the Video). As I indicated to you, a sensitive, caring psychologist and a patient with sufficient ego strength that she can face pain even though the grief goes back a number of years and is very intense. I wanted to ask you some questions in terms of how you feel the Rorschach and the SIS helped us clinically especially as it relates to therapy. As you know I have been very interested in a content analysis approach. I had the privilege years ago of working with Professor Seymour Fisher on the Rorschach and SIS anatomical responses presented by people who had somatic symptoms. Ultimately, I realized that we needed projective stimuli with more anatomical content and so on and have been stimulated originally by reviewing some of Dr. Schafer’s work on the psychoanalytic content analysis and others more recently such as Lerner (1991). It was fascinating for me to realize that you had met Piotrowski toward the end of his life and that he himself was interested in psychoanalytic content analysis. Could you share about that please, especially in terms of Mrs. X's responses? Dr. D: I use both the tests SIS and Rorschach on clinical cases. 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 somatic manifestation, though the causes are psychological in nature. Dr. C: Exactly. A lot of people cannot verbalize their emotional issues and tend to somatize. In medical and hospital set up, physicians and nurses, who focus on the physical symptoms, reinforce it. Many either does not have time or the training to work on the psychological issues is not adequate. Dr. D: Yeah. And more often I have found that people express their psychological problems through physical symptoms. Dr.C: 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. The medicine (anti-depressant) is not going to help her much. Her problem is probably because of her psychological/ emotional attachment with her father, which she is unable to resolve after his death. Interpretation 143

Dr.C: 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-video images have created hypnotic like effect and she started coming out. 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.C: 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, that release feelings and help them understand themselves. Dr.D: Many psychologists working in teaching set up and not really trained in handling patients do not believe much in projective tests and particularly in inkblot procedure. They believe more in questionnaires because it does not require any training and sophistication in interpretation. Dr.C: 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 cards # 2,8,9 and 10 were very informative and effective in this case. Dr. C: Yes. Dr. D: She was very upset on chromatic cards. Dr.C: 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.C: 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 put such responses under closed scoring categories. For example, on Card #8 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 its content analysis. Dr.C: Correct and this is how the inner cry can be trapped through content analysis. Dr. D: What she perceived is her real situation. 144 Interpretation

Dr. C: It makes it more real when you have a stimulus than just talking in generalities in an interview. Dr.D: Exactly. And on card #9 again she perceives “a person hiding behind and feeling ashamed like me”. This is true projection which one can never imagine on questionnaires. Dr.C: 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. Dr.C: Right. Dr.D: And on the basis of such responses you cannot put her under schizophrenia. Dr.C: That’s right. Dr.D: Such responses can be explained through psychoanalytic interpretation. Dr.C: 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.C: 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.C: So it is very important that the therapist ultimately goes back and makes these interpretations. Dr.D: Exactly, this is what Dr. Piotrowski (1985) explained me when I visited him at his Logan's Square home in Philadelpha 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 contents of given responses. Dr.C: Yes. Dr.D: Because after all why psychological tests are done? It is only to help in getting more and more information about the patient. Dr.C: We want information which is clinically relevant to the therapy process. Dr.D: Exactly, and that is why out of 62 images on SIS, I was interested only in a few images giving more clues. Interpretation 145

Dr.C: Right. What is your feeling about rating the images for their degree of threat and then starting with those that are most threatening? Dr.D: The images rated as most threatening help in understanding the psychopathology of the subject. Such images depict specific body imagery and traumatic experiences way back in time. In fact it is not the 20 cards of SIS- I or 62 images of SIS -II/Video but the three most threatening images which will provide you signals to peep into the inner self of the subject. Dr.C: Yes. Dr. D: And you make depth interview to understand the causes of threat/repression. Dr.C: And then in instances where there is somatic repression then only those that are relevant. Dr.D: Exactly, may be out of 20 you have only five or six cards to go through. Dr.C: Right. Dr. C: Other cards you can leave aside. Dr.C: 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.C: Yes. Dr. D: It is painful to imagine but there are many more such persons facing to cancer bravely. Dr.C: 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.C: 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.C: Would you be concerned about suicidal ideation with her in view of this death 146 Interpretation

preoccupation? 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. C: Yes. Dr.D: And that is why she is not talking about suicide. Dr.C: Yes. Dr.D: She is aware of her medical profile. Her strength is still her consideration and caring attitude towards her family. Dr.C: 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 she is bound to give such responses on SIS images. Dr.C: Thank you for your most interesting comments. What would you recommend in terms of someone considering the use of the SIS as opposed to existing techniques including non projective tests? Dr.D: What I have noticed that 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 loading. 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.C: Yes. Dr.D: And in fact, in one of my studies where I tried to find 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 as well as therapeutic instrument. 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 individual. So this way you can get more information which is not possible through tests like the Rorschach and the Holtzman. This SIS is not against the Rorschach test but it is further extension of the Rorschach. The SIS was tried in India during selection and was found to be a successful instrument in getting the right man on job. Dr.C: 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 Interpretation 147

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 his turn in the clinic. So because of these qualities it is the best projective test. Dr. C: 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. Dubey. 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 that 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 identificaiton with her father’s deteriorating body image contributed to her converting the diseased anatomicial imagery into repressed affect, leading to physical symptoms of chest pain and marked cancer phobia. Copies of the videotape of this interview completed in 1991 may be obtained by writing to the authors. This may be sent to those interested individuals who might wish to use it for teaching purposes. Even though Mrs. X signed a statement giving permission for its educational release, it is not available in the United States or Canada to protect her confidentiality. The authors apologize for the lack of editing in the transcript, but it is our belief that if one employs a case history phenomenological approach, accuracy in reporting is far more valuable to the scientific methodology than grammatical organization. Acknowledgement The authors are grateful to the patients for their cooperation and thanks them for their permission to use the material in this Manual for educational purpose. The name of the patients mentioned in the case report is fictitious to hide their identity. 148 Interpretation

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Adamson, 23,67,70 Agrawal, 13,35 Alexander, 17 Baker,5 Banerjee,12 Bartlette, 5 Baughman, 7,8 Baumgarten, 6 Binet, 5,6 Botticelli,5 Cassell, 5,6,9,10,11,12,13,14, 20,23,26,28,32,33,34,35,36, 45,67,68,70,76,79,81,101, 129,135,143 Cella, 80 Chaudhary,12 Cleveland,9 Croog,26 Csikszentmihally, 41 Da Vinci,5 Dearbron, 5,6 Dosajh,12 Dubey, 5,7,8,12,13,20,23, 24,26,28,30,31,32,33,34, 35,36,68,69,76,79,98,101 Dwivedi, C.B., 25,29 Dwivedi,P., 13,32,34,35,36,68 Exner, 5,9 Fiske,7,8 Fisher, 9 French, 17 Freud, 17 Gaetani,68 Gehring, 6 Goel, 23 Gould, 80 Graham, 14 Greengrass, 23,70 Henry, 5,6 Hertz, 20 Hinkle, 5 Hollender, 9,67 Hottzman, 5,7,8,20,40 Kaur, 12 Kielholtz, 10 Krikpatrick, 5 Krugman, 5 Kubey, 41 Kumar, 12 Kwialkowska, 45 Learner, 71, 143 Author Index Martin, 71 Matthew, 14 Mishra, 13,25,28,29,36,37,68 Michison, 69 Mitra, 12 Mohn,12 Morgenthaler, 5 Morton,5 Mukhopadhyay, 12,68 Nelson, 5 Nicolini, 12 Ojha, 5,6 Overholzer, 5 Palia, 13 Pandey, 12 Panek,12 Parsons, 5 Pelocovitz, 80 Pershad, 32,34,35 Pyle, 5 Rathee, 12,68 Reynolds, 6 Roemer, 5,6 Rorschach, 5,6,8,9,17,20 Rybakow, 6 Rossi, 120 Saldanha, 68 Sarkar, 12 Savage, 26,74 Schafer,16,17 Schumer, 5,40 Sharma,V,K., 96,98 Sharma,V.P., 5,7 Sharp, 5 Shin, 70 Singh, 30,31,68 Sperbeck, 12 Srivastava, 12 Sundberg, 5,6 Tewari, 13 Tross, 80 Ulman, 45 Vagrecha, 5,7 Verma, 12,13 Vernon, 20 Wade, 5,7 Wentinck, 16 Whipple, 5,6 Wickelgren, 14 Zubin, 5,6,7,40 Author Index 161

Adolescent norms, 36 Aggression, 31 Alcoholic response, 30 Anatomy response, 20-38,45-46 Animal response, 20-38,45-46 Anxiety reaction, 37 Apple response, 48 Bird response 48,49,50 Brain response 53 Chest 50,54 Clown response, 48 Content validity, 22-23 Death scene, 73 Depression, 31,37 Dream programming, 76,107 Drug dependent response, 30-31 Ear response 49,55 Executive norms, 35 Eye awareness, 49,51 Female genitalia, 48-49, 50-51,54 Fruit response 48 Gastrointestinal tract, 49-50 Hand response, 49 Headache, 81 History of inkblots,5 Hostility aggression scale, 31 Human response, 20-38, 45-46 Hypnosis, 83,99 Intestine, 49-50 Kidney,49,52 Subject Index Lips, 48 Lungs, 48,52 Most Typical, 20-38, 45-47 Mouth response, 48,53 Movement response, 21-38, 45-46 Neurosis, 24-25,27 Normative data, 32-36 Nose response, 52 Paranoid response, 31 Pathological anatomy scale, 31 Penis response, 53 Rajection of Images, 21-38 Reliability, 19-22 Rib cage, 50,54 Schizophrenia 24-25,27 Scoring, 45-57 Sex response, 20-38,45-46 Skull response, 51,53 Somatised pain, 104,134 Spinal column, 50,53 Stammering, 81 Successful indices, 35 Suicidal ideation, 56 Test administration, 39 Total response, 51 Treatment application, 67-148 Typical response, 47-55 Vagina response, 51 Validity, 22-23 162 Subject Index

THE SOMATIC INKBLOT SOCIETY I wish to be a Member __________ a Life Member ________ of the Somatic Inkblot Society. Please submit this request to the Membership Committee. NAME ____________________________________ Birth date __________________ (Print or type) First Middle Last ________________________________________________ Zip _________________ Business/Office Address : ________________________________________________ ______________________________________________Tel. : (W)_________________ ___________________________________________________(H)_________________ EDUCATION Degree Year Institution Major Field of Study EMPLOYMENT : Current position, employer, dates (Graduate Students indicate area of study and degree toward which you are working). MEMBERSHIP : ________________________________________________________ TRAINING AND EXPERIENCE IN PERSONALITY ASSESSMENT : SPONSOR (S) Name Address Telephone 1. ____________________________________________________________________ 2. ____________________________________________________________________ SIS subscription payable every year in January through Cashier Cheque/Draft I certify that the information provided above is accurate and correct. An APPLICATION FEE Cheque is enclosed for Foreign Members ($40) & Life Membership ($300). For Members in India Rs. 250/- & Life Membership Rs. 2000/- Total Cheque $/Rs._______________Drawn at________________________________ Signature of applicant : _______________________________ Date :_______________ PLEASE RETURN with your cheque to : B.L. Dubey, Ph.D., Vice-President, Post Box No. 1107, Sector 15 Post Office, Chandigarh – 160 015 (India). Tele/Fax : 91-172-710986, Tel. : 91-172-710985, E-mail : sisdubey@hotmail.com OR sisdubey@rediffmail.com Web Site : http://www.somaticinkblots.com Make cheques payable to Somatic Inkblot Society, Chandigarh (India) N.B. : Please add Rs. 50/- as one time registration fee; and $5 / Rs. 60 if you are sending subscription through out station cheque.

Professional Quality VHS Videotapes (specify NTSC, PAL or SECAM), as well as Audio Tapes and Transcripts of Interviews are Available for Teaching/Clinical Purpose. Police case--"Witnessing an Accident" Vietnam veteran -- "Unresolved Guilt" Therapeutic Dream Stimulation Anniversary Reaction to Miscarriage Grieving a Still Birth Conversion Reaction Fear of cancer and hypochondriasis (includes Rorschach imagery) Alcohol and Cocaine Depended Father/Son Incest Teen-age Alaska Native's Death by Gas Inhalation Suicide Behaviour in Adolescent Alaska Native Nightmare Vision (sexually abused adolescent girl and absence of father figures in black adolescent boy) Auschwitz Revisited Neuropsychological Reactions to Life Threatening Accident & SIS Occupational Stress and the SIS The use of the SIS as an Aide in Meditation while grieving a Miscarriage SIS-Video (A&B Series) SIS-I Videotape SIS-Living Images A Walk Through The Garden of Life and many more Audio & Videotapes Contact : SIS Center, 4501 E, 104th Ave, Anchorage, Alaska-99516 (USA) E-mail : drcassell@gci.net OR sisdubey@rediffmail.com Web Site@http://www.somaticinkblots.com for getting the above material

James Chapman, who wrote extensively in the 1960’s about the early symptoms of schizophrenia, commented; “What interests me about this interview technique is its use of the well-known mechanism of projection. The diagnosis of schizophrenia is based on detecting a whole series of signs and symptoms. However, certain mental changes are subjectively experienced by the young schizophrenic much before these signs and symptoms, such as delusions and hallucinations, appear. This technique, because of its anatomical and bodily content, and also because it is visual, allows the patient to describe, by means of projection, some early changes in mental function and some early symptoms, such as preoccupation with the body. It allows the observer to examine the mental state and performance of the young schizophrenic in a more detached fashion than a traditional interview. It is, therefore, possible that this interview technique could well prove to be a very useful aid in the early clinical diagnosis of schizophrenia”. - James Chapman What others say... The SIS-Video has promising applications in the rapidly growing field of telemedicine. This is particularly important for the evaluation and treatment of Native Alaskans in isolated, geographically remote areas. The technology employs state of the art still image phones between the Anchorage SIS center and rural native hospitals. This technique is in line with the profession’s growing recognition of the need to make state-of-the-art treatment technology available to remote centers. Dr. Cassell’s procedure is in a format that will allow its utilization by Alaskan Native communities as they strive to develop culturally relevant healing programs. The Somatic Inkblot Series Manual is very well elaborated and is of great help to clinicians and research health professionals. Moreover, it provides a technologically derived conceptual background for those embarking on careers encompassing the physical - psychological - spiritual dimensions of life. Those trained should communicate more empathetically in evaluating and caring for suffering individuals. Because it is based more on visual imagery - the media of dreams, poetry and art-it enables those trained to more effectively bridge cultural boundaries. - Robert Morgan, Ph.D. Director of Behavioral Health, Alaska Native Foundation, Anchorage, Alaska.

What others say... The Somatic Inkblot Series is certainly worthwhile to add to the techniques currently in the marketplace. The manual is full of clinical wisdom and useful hunches that will be value to the reader, and contains within its pages a summary of much valuable theoretical and practical value....” -Walter G. Klopfer The inkblot technique developed by Dr. Cassell has intriguing potential. It derives from a recognition that we all entertain complex images about our own bodies and that our style of behavior in the world is affected by these images. There is already solid evidence that the formless context of the inkblot is particularly effective in eliciting our unconscious body feelings and fantasies. Dr. Cassell has boldly tackled the problem of constructing an inkblot series that will maximize the projection of body imagery in general and also feelings about specific sectors of one’s body. He has made excellent progress in exploring the applications of his inkblot series and we may anticipate that it will prove to have valuable research and clinical value. -Seymour Fisher