Part 28

On examining a dream it was found to be peculiar in one respect: It was not an imaginative or fantastic composition, but a detailed and precise living over again of the scenes at the death bed: that is to say, it was a sort of somnambulistic state. In recalling this dream[188] she could not for some time recover the ending. Finally it “broke through,” as she expressed it. The dream was as follows: First came many details of the vigil of the last night of the illness; then she went to her room and to bed to snatch a few moments’ sleep; she was waked up by the husband of the dying relative appearing in her room. He sat on the edge of her bed and said to her, “All is over.” Up to this point the facts of the dream were actual representations in great detail of the actual facts as they had occurred, but at this moment the dream presented a fact which had not occurred in the real scene; she suddenly, in the dream, sat up in bed and exclaimed, “My God! then I ought to have sent for the doctor!”

Here was the key to the intolerance for memories of the illness of the relative and the death-bed scene. What had happened was this: The question had arisen early in the illness whether or not a doctor should be sent for from London in consultation. The expense, owing to the distance, would have been considerable. The whole responsibility and decision rested upon the subject. Against the opinion of other relatives she had decided that it was inadvisable. After the fatal ending the question had arisen again whether or not she ought to have sent for the consultant and she had been tormented by the doubt as to whether she did right; _was the fatal result her fault_? Although she had reasoned with herself that her decision was good judgment and right still there had always lurked a doubt in her mind. She was also somewhat disturbed by the thought of what the husband’s opinion might be.

The real reason why she could not tolerate the memories of the last illness of this relative, and the psychogenesis of the symptoms now were plain: they were not grief but self-reproach with its instinct of self-abasement. The memories brought to her mind that the fault was her’s and with the thought came self-reproach. _This self-reproach she was afraid of and unwilling to face._ This fact she recognized and frankly confessed after the disclosures of the analysis.

Now follows the therapeutic sequel. The relative’s illness at the beginning was in no way of a dangerous nature and the proposed consultation had nothing to do with the question of danger to life. The death was due to purely an accidental factor and could not have been foreseen. When I assured her in hypnosis, with full explanation, that her decision had been medically sound, as it was, the change in her mental attitude was delightful to look upon. “Wasn’t it my fault! Wasn’t it my fault!” she exclaimed in excitement. Anxiety, dread, and depression gave way to exhilaration and joyousness. Thereupon she woke up completely relieved in mind, and retained the same feeling of joy, but without knowing the reason thereof. The explanation was repeated to her in the waking state and she then fully realized (as she did also in hypnosis) that her previous view was a pure subterfuge and fully appreciated the truth of the discovered reason for her inability to face her painful memories. The twilight states, the insomnia, and the distressing dreams, the anxiety, and other symptoms ceased at once.

Returning to the phobia for bells, in the light of all these facts, the patient’s belief that her mother’s death was her fault and the consequent self-reproach were obviously only a particular concrete example of a lifelong emotional tendency originating in the experiences of childhood to blame herself; and this tendency was the striving to express itself of the instinct of self-abasement (with the emotion of self-subjection) which, incorporated within “the self-regarding sentiment” (McDougall), was so intensely cultivated and had played so large a part in her life. Indeed this instinct had almost dominated her self-regarding sentiment and had given rise time and again to self-reproach for accidental happenings. It now specifically determined her attitude of mind toward the series of events which led up to the fatal climax and determined her judgment of self-condemnation and self-reproach. These last most probably received increased emotional force from the large number of roots in painful associations of antecedent experiences (particularly of childhood) in which the self-regarding sentiment, self-debasement, and self-reproaches were incorporated.[189] _Nevertheless the fear was of a particular concrete self-reproach._ The general tendency was of practical consequence only so far as it explained the particular point of view and might induce other self-reproaches.

As a general summary of this study it would appear that we can postulate a larger setting to the phobia than the grief inspiring experiences attending her mother’s death. The unconscious complex included the belief that she was to blame and the sentiment of self-reproach, and the whole gave a fuller meaning to the ringing of bells in a tower. The fear besides being a recurring association was also a reaction to the subconsciously excited setting of a fancied truth or self-accusation. Although excited by towers and steeples the fear was really of self-reproach. Towers, steeples, and bells not only in a sense symbolized her mother’s death, but her own fancied fault. It was in this sense and for this reason that she dared not face such objects. The conscious and the unconscious formed a psychic whole.[190]

Now in reaching these conclusions see how far we have traveled: Starting with an ostensible phobia for towers, we find it is more correctly one of ringing-of-bells, but without conscious association; then we reach a childhood’s tragedy; then a self-reproach on religious grounds; then a belief in a fault of childhood’s behavior culminating in a lifelong self-reproach—the causal factor and psychologically the true object of the phobia: and between this last self-reproach and the phobia no conscious association.

The _therapeutic_ procedure and results are instructive. As the fear was induced by a belief in a fancied fault exciting a self-reproach, obviously if this belief should be destroyed the self-reproach must cease and the fear must disappear. Now when all the facts were brought to light, the patient, as is usual, recognized the truth of them. She also recognized fully and completely the real nature of the fear, of the self-blame and of the self-reproach. There remained no lingering doubt in her mind, nevertheless the bringing to “the full light of day” of all this did not cure the phobia. As the first procedure in the therapeusis it was pointed out that it was contrary to common sense to blame herself for the heedlessness of a child; that all children were disobedient; that she would have been a little prig if she had been the sort of a child that never disobeyed, and that she would not have blamed any other child who had behaved in a similar way under similar circumstances, and so on. She simply said that she recognized all this intellectually as true and yet, although it was the point of view which she would take with another person in the same situation, it did not in any way alter her attitude toward herself. In other words the bringing to the full light of day of the facts did not cure the phobia. It was necessary to change the setting of her belief. _To do this either the alleged facts had to be shown to be not true or else new facts had to be introduced which would give them a new meaning._ This, briefly told, was done in the following way:

She was put into light hypnosis in order that exact and detailed memories of her childhood might be brought out. Then, through her own memories, it was demonstrated, that is to say, the _patient herself demonstrated_, that there was considerable doubt about her having had phthisis at all; that she was not taken to the usual places of “cures” for phthisis but sojourned in the gay and pleasant cities and watering places of Europe; that her mother really staid in Europe because she enjoyed it and made an excuse of her daughter’s health not to come home; that she might have returned at any time but did not want to do so; and that the fault lay, if anywhere, with her physician at home. When this was brought out the patient remarked, “Why, of course, I see it now! My mother did not stay in Europe on account of my health but because she enjoyed it, and might have returned if she had wanted to. I never thought of that before! It was not my fault at all!” After coming out of hypnosis the facts as elicited were laid before the patient; she again said that she saw it all clearly, as she had done in hypnosis, and her whole point of view was changed.

The therapeutics, then, consisted in showing that the alleged facts upon which the patient’s logical conclusions had been based were false. The setting thereby was altered, and a new and true meaning given to the real facts. The result was towers and steeples no longer excited fears, the phobia ceased at once—an immediate cure.[191]

_Type D._ In this type _the conscious psychosis consists of idea, meaning, affect, and physical disturbance_. F. E. suffered from attacks of so-called “unreality” accompanied with intense fear. She was unable to give an intelligent explanation as to why she was afraid of the attacks—harmless in themselves—until it was brought out that there was in the _background of her mind_ the thought that the attacks spelled insanity (or that she was likely to go insane) and also death. Following the attacks there was amnesia for these thoughts. Her fear really, then, was of insanity and death. The content of consciousness in the attacks contained the perception of herself as an insane person, thoughts which expressed the meaning of her attacks, and fear. (The usual physical disturbances of course accompanied the fear.) No amount of explanation of the harmlessness of the unreality syndrome sufficed to change her point of view, i.e., its meaning to her. But going further it was discovered that her self-regarding sentiment and her ideas of insanity and death were organized with a large number of fear-inspiring antecedent experiences which explained why she regarded the attacks as dangerous to her mentality and life; and why the biological instinct of fear was incorporated with the self-regarding sentiment. These experiences had long passed out of mind and there was no conscious association between them and her phobia, but they could be recalled as associative memories.[192] The unreality attacks had for her two meanings which were within the content of consciousness, viz., 1, insanity, and 2, death. The first was derived from (a) antecedent girlhood and later experiences which had engendered the unsophisticated belief that having the mind fixed on one subject, as was obtrusively and painfully the case at one time, meant insanity: and (b), from the fact that the bewildering, irreconcilable, absurd thoughts, conflicts, and emotions in which the unreality attacks culminated meant insanity.

The second meaning (death) was derived from (a) the previous fixed idea (just referred to), organized with that of insanity—namely, an unsophisticated medieval idea of hell which was conceived of as the equivalent of death and which had excited an intense horror of both; and (b) from the fact that in the unreality attacks there was a _struggling_ for air; struggling was in her mind, the equivalent of convulsions;[193] convulsions of unconsciousness; and unconsciousness of death. All these various ideas and the intense fears which each gave rise to had become organized into a complex, and, in consequence of these antecedent experiences in which self took a prominent part, the instinct of fear—as I conceive the matter—became incorporated within the self-regarding sentiment. (Anything that aroused this sentiment tended to arouse the emotion of fear, as in another person it would tend to arouse the emotion of pride, or self-abasement.) At any rate this organized complex was the setting which gave the meaning to her phobia. There can be, I think, no manner of doubt about this. The patient herself explained her viewpoint through these ideas here briefly summarized. The only question is as to the mechanism of the phobia. Now as Type D, of which these cases are examples, differs clinically from the preceding three types only in the addition of one more element—meaning—to the conscious psychic whole, a consistent interpretation would seem to compel us to postulate also a functioning subconscious complex or setting and in this case of the antecedent experiences disclosed as a factor in the mechanism and a part of the psychic whole. Out of this complex emerged into consciousness the idea of insanity and death and fear as the meaning of the unreality syndrome, the whole constituting the phobia psychosis.

That there was in fact a subconsciously functioning process derived from this complex would seem to be almost conclusively shown by another phenomenon manifested. I refer to the vivid _visualization of herself in a convulsion, struggling for air and manifesting fright_, which she experienced in each attack. We have seen that such a visualization (i.e., a modified vision) is the expression (secondary images?) of a subconscious process (co-conscious ideas?). As a matter of fact this particular visualization was a pictorial representation of antecedent thoughts organized with thoughts of death and insanity and still conserved in the unconscious. We must believe, then, that it was these antecedent thoughts (in the first place her apprehension of inheriting Bright’s disease and convulsions from her father, and in the second place her conception of the unreality syndrome as a state which might possibly end in convulsions) which, functioning subconsciously, induced the quasi hallucinatory expression of themselves.[194] It is difficult to get away from the conclusion that the remainder of the setting from which the ideas of insanity and death were derived also functioned as a subconscious process. Whether this process was conscious or unconscious is a secondary question which we need not consider.

In weighing the probabilities of this interpretation we should bear in mind that there were two conscious beliefs of which the patient was fully aware and which were very real to her; namely, the liability of becoming insane and to convulsions and death. The conative force of the instinct of fear linked to such ideas is quite sufficient to drive them to expression when out of mind and subconscious. Or expressed differently we may say that the fear was a reaction to these ideas which the patient dared not face.

We ought not, however, to be too sweeping in our generalizations and go further than the facts warrant. We are not justified in concluding that the linking of an affect to an idea always includes a subconscious mechanism. On the contrary, as I have previously said, probably in the great majority of such experiences, aside from obsessions, no such mechanism is required to explain the facts.

_The Inability to Voluntarily Modify Obsessions._—We are now in a position on this theory to look a little more deeply into the structure and mechanism of an obsession and thereby realize why it is that the unfortunate victims are so helpless to modify or control them. Indeed this behavior of the setting could be cited as another piece of circumstantial evidence for the theory that the setting is largely unconscious and that only a few elements of it enter the field of consciousness. If we simply explain to a person who has a true obsession, i.e., an insistent idea with a strong feeling tone, the falsity of the point of view, the explanation in many cases at least has no or little effect in changing the viewpoint, though the patient admits the correctness of the explanation. The patient cannot modify his idea even if he will. But if the original complex, which is hidden in the unconscious and which gives rise to the meaning of the idea, is discovered, and so altered that it takes on a new meaning and different feeling tones, the patient’s conscious idea becomes modified and ceases to be insistent. This would imply that the insistent idea is only an element in a larger unconscious complex which is the setting and unconsciously determines the viewpoint. The reason why the patient cannot voluntarily alter his viewpoint becomes intelligible by this theory, because that which determines it is unconscious and unknown. He may not even know what his point of view is, owing to the meaning being in the fringe of consciousness.

If this theory of the mechanism is soundly established the difficulty of correcting obsessions becomes obvious and intelligible. It is also obvious that there are theoretically two ways in which an obsession might be corrected.

1. A new setting with strong affects may be artificially created so that the perception acquires another equally strong meaning and interest.

2. The second way theoretically would be to bring into consciousness the setting and the past experiences of which the setting is a _sifted_ residuum, and reform it by introducing new elements, including new emotions and feelings. In this way the old setting and point of view would become transformed and a new point of view substituted which would give a new meaning to the perception.

Now in practice both these theoretical methods of destroying an obsession are found to work, although both are not always equally efficacious in the same case. In less intense obsessions where the complex composing the setting is only partially and inconsequently submerged, and to a slight degree differentiated from the mass of conscious experiences, the first and simpler method practically is amply sufficient. We might say that the greater the degree to which the setting is conscious and the less the degree to which it has acquired, as an unconscious process, independent autonomous activity the more readily it may be transformed by this method.

On the other hand in the more intense obsessions, where a greater part of the setting is unconscious, has wide ramifications and has become differentiated as an independent autonomous process, the more difficult it is to suppress it and prevent its springing into activity whenever excited by some stimulus (such as an associated idea). In such instances the second method is more efficacious. It is obvious that, so long as the setting to a central idea remains organized and conserved in the unconscious, the corresponding perception and meaning are always liable under favoring conditions (such as fatigue, ill health, etc.) to be switched into consciousness and replace the new formed perception. This means of course a recurrence. Nevertheless medical experience from the beginning of time has shown that this is not necessarily or always the case. The technique, therefore, of the treatment of obsessions will vary from “simple explanations” (Taylor) without preliminary analysis to the more complicated and varying procedures of analysis and re-education in its many forms.

_Affects._—Here a word of caution in the interpretation of emotional reactions is necessary. In the building of complexes, as we have seen, an affect becomes linked to an idea through an emotional experience. The recurrence of that idea always involves the recurrence of the affect. It is not a logical necessity that the original experience which occasioned the affect should always be postulated as a continuing subconscious process to account for the affect in association with the idea. It is quite possible, if not extremely probable, that in the simpler types, at least, of the emotional complexes, the association between the idea and affect becomes so firmly established that the conscious idea alone, without the coöperation of a subconscious process, is sufficient to awake the emotion; just as in Pawlow’s dogs the artificially formed association between a tactile stimulus and the salivary glands is sufficient to excite the glands to activity, or as in human beings the idea of a ship by pure association may determine fear and nausea, the sound of running water by the force of association may excite the bladder reflex, or an ocular stimulus the so-called hay fever complex. So in word-association reactions, when a word is accompanied by an affect-reaction the word itself may be sufficient to excite the reaction without assuming that an “unconscious complex has been struck.” The total mechanism of the process we are investigating must be determined in each case for itself.

In the study and formulation of psychological phenomena there is one common tendency and danger, and that is of making the phenomena too schematic and sharply defined, as if we were dealing with material objects. Mental processes are not only plastic but shifting, varying, unstable, and undergo modifications of structure almost from moment to moment. We describe a complex schematically as if it had a fixed, immutable, and well-defined structure. This is far from being the case. Although there may be a fairly fixed nucleus, the cluster, as a whole, is ill defined and undergoes considerable modification from moment to moment. New elements enter the cluster and replace or are added to those which previously took part in the composition. An analogy might be made with a large cluster of electric lights arranged about a central predominant light, but so arranged that individual lights could be switched in and cut out of the cluster at any moment and different colored lights substituted. The composition and structure of the cluster, and the intensity and color of the light, could be varied from moment to moment, yet the cluster as a cluster maintained. We might carry the analogy farther and imagine the cluster to be an advertising sign which had a meaning—the advertisement. This meaning might or might not be altered by the changes in the individual lamps.

The same indefiniteness pertains to the demarcation between the conscious and the subconscious. What was conscious at one moment may be subconscious the next and _vice versa_. Under _normal_ conditions there is a continual shifting between the conscious and subconscious. I have made numerous investigations to determine this point, and the evidence is fairly precise, and to me convincing, that this shifting continually occurs,[195] as might well be inferred on theoretical grounds. Nor, excepting in special pathological and artificial dissociated conditions, is the distinction between the conscious and subconscious at any moment always sharp and precise; it is often rather a matter of vividness and shading, and whether a conscious state is in the focus of attention or in the fringe. Experimental observation confirms introspection in this respect.