From the Division of Psychiatry, University of California Medical School, and the Langley Porter Clinic, San Francisco, California.
This is the third paper in a series entitled: Experiments in Psychotherapy.
IN A STUDY of the personality of patients suffering from post-traumatic syndromes (30, 31, 32), chronic disease in general (33), duo-denal ulcer (35), and thyroid conditions (34) it became more and more apparent that a common denominator existed in the majority of these psy-chosomatic conditions. Symptomatology (33), per-sonality structure (40), as well as social techniques (37) of these patients pointed to a rather primitive level of psychologic organization. Further evidence for immaturity was found in the need for modifica-tion of psychotherapeutic procedures commonly employed in the treatment of psychoneuroses for use in the rehabilitation of these patients (33). The common denominator then was identified as re-lated to faulty or arrested maturation, and somatic manifestations were recognized as constituting means of infantile self-expression. In the present paper an attempt is^made to discuss the immature personality as related to psychosomatic conditions, thus providing a better understanding of the psy-chotherapeutic needs of these patients.
Theoretical Considerations
When an individual goes through the various phases of psycho-physical development and then breaks down, terms such as fixation and regression have been introduced to denote that the individual returned to previous levels of adjustment and gratification (18, 20), and if an individual ex-presses certain repressed conflicts by means of symbolic physical symptoms, this process is called conversion (19). Most of these concepts have been derived from the study of highly organized and complex types of psychoneuroses (15). Then, some years ago, the attention of the psychiatrist shifted to the psychosomatic conditions. Though the con-cept of conversion was separated from the concept of vegetative neuroses (4), the attempts at corre-lating specific conflict situations with specific syn-dromes implied the use of the concepts of conver-sion and regression (2). At closer examination of these reports (12), however, one is struck by the importance which various authors (7, ri, 22, 27, 42, 44) attribute to features such as dependence, low frustration tolerance, vegetative or autonomic manifestations, specific and stereotype somatic re-actions to various types of frustration, and poor or one-sided manipulative ability of these patients. All features mentioned are characteristic of immature personalities and tend to corroborate the author's own conclusions (38, 40). Therefore, it seems justifiable to state how some of the theoretical concepts and therapeutic methods used in the treat-ment of complex and organized psychoneuroses have to be modified when applied to psychosomatic conditions. In the psychoneuroses we deal with a pathologic development, while in psychosomatic conditions one meets primarily arrested develop-ment. Some of these infantile patients, for example, have persisted since childhood in expressing them-selves in somatic terms, though visible pathology developed only after certain habits persisted for a number of years. In these cases it would be erron-eous to apply terms such as regression and conver-sion, when in reality a lack of progression has existed, to which attention is called when physical pathology is discovered. Rehabilitation in such cases is frequently a modified form of child psycho-therapy with chronologically adult patients.
Thus the most relevant clinical problem in psy-chosomatic conditions seems to center around the level of organization at which patients habitually operate. Since maturation is understood best in terms of social learning, reference will be made to the concepts of drive, cue, response, and reward (26). A drive impels a person to respond; a re-sponse as such is action, at first nonsystematized and later learned and organized. Cues determine when and where an individual will respond and which responses he will make. Whether a given response or action will be repeated depends on whether or not it is going to be rewarded. The process of emotional and intellectual maturation, then, consists of correct generalization of responses from the physical to the social sphere, acquisition of cues, discrimination, symbolic self-expression, de-velopment of social techniques and, finally, in-tegration. The state of maturity (6, 43, 45) as op-posed to the state of immaturity (21, 24, 25) is characterized by essentially three features: a) suc-cessful functioning as an independent unit with gratification of wishes in terms of the culture in which the individual lives (36); b) successful bio-logic and social interaction with other people (37); c) self-expression, self-extension, self-objectivation (6, 36). As space precludes further elaboration of the concepts set forth, the reader is referred to the original publications (36, 37). In applying the theory outlined, one arrives at the following illus-tration of the immature personality.
Arrested or Faulty Social Learning
In terms of the theory of social learning, the in-fantile personality is characterized by the follow-ing criteria:
Genetic childhood events leading to faulty or ar-rested social learning are:
Genetic childhood processes leading to faulty or arrested social learning are:
Precipitating events leading to first occurrence or recurrence of physical symptoms in partially ma-ture people are:
Poor symbolic self-expression is the result of ar-rested development. The average person learns self-expression in three well-defined steps:
First step: the child generalizes modes of action to the social sphere and learns to expend excess tension in interpersonal relations. If this step is only partially or incompletely mastered because of unsatisfactory early interpersonal relations, self-ex-pression remains on the level of organ responses, either muscular, visceral, or vascular (8, 36, 37). For example, intake, retentive, and output func-tions can be carried out not only by the intestinal tract, but the individual as a whole can apply these modalities in social action. If for some reason this step cannot be undertaken one deals with a partial response of the organism (psychosomatic condi-tion), and not with the distorted total response which is symbolized in one organ system (con-version hysteria).
Second step: if die child is able to generalize, then the processes of discrimination and learning of certain social cues result in organization of more complex actions. Feelings, emotions, and conflicts are expressed at diis level in terms of doing some-thing that will convey to others the desired mean-ing, or which will elicit emotions in the other per-son. Children and adults remain on this level of acting out (1) all internal events or of partici-pating in actions of others by means of projection or identification if the third step, namely, symbolic expression cannot be mastered.
Third step: successful maturation is dependent upon the individual's ability to learn to express or-gan responses, as well as whole actions, symboli-cally (28). Verbal, gestural, artistic, or other ex-pression results in almost as much satisfaction as if organ or action responses had been carried out in full. Symbolic expression (6) widens the sphere of influence and permits more action per unit of time. Mature people operate on a level at which symbolic expression predominates, expression through action has a lesser share, and organ expres-sion is negligible.
Self-Expression and Somatic Manifestations
In sham maturity, or nominal acceptance of symbols, we do not deal with self-expression but with an infantile manipulation of symbols with-out corresponding participation of the individual. The exteroceptive cues are known to the individual but the corresponding proprioceptive cues do not arise within that person. Self-expression then oc-curs on either the level of action or organ expres-sion, especially with regard to tension. Mature persons can discharge tension through initiation of action to remove the cause of the frustration or in-terference, and expend any excess tension through verbal, gestural, or creative symbolisms in inter-personal relations. Immature persons can do neither. They simply get stuck with their tension. This, in turn, means that heart rate, blood-pres-sure, muscular tension, and other mechanisms used for preparation for action are abused (3). In the mature person, action in itself returns the or-ganism to a resting condition, while lack of action in the immature person does not terminate the organism's readiness for action. It seems as if this prolonged state of readiness for action without re-demption can lead to vascular and intestinal pathol-ogy (38, 43). This hypothesis is supported by the observation that when a patient can learn to initiate action or to express frustration through verbal com-munication, physical symptoms tend to disappear. The reverse is true of people who act out (8), in-asmuch as immobilization of such persons usually promotes reappearance of symptoms. This concept would lead to the following classification of psycho-somatic conditions:
Perception, Thinking, and Ideation
The infant's experiences have different dimen-sions than those of the adult. This is the result of extrauterine maturation which at various stages (13, 14) emphasizes different functions and mo-dalities of action. The adult, in turn, is not compelled to use certain modalities more than others. If he does, it is the result of cultural influences or of traumatic events in early childhood. Distortion of the problems of prestige, intimacy, and identity can occur (37) when mastery is not achieved and control is substituted for it. In such cases the child's thinking has become distorted and gratification has been projected into the future. For ex-ample, a child might consciously expect that by next year he will be taller and bigger and stronger, that he will have more rights, more abilities, more skills, and that he can satisfy more demands. This experience of growth leads to a faulty generaliza-tion which teaches the child to set ideals and goals well ahead of real ability. As the child gets older the period of rapid growth ends. Goals and ideals have to be reset, and instead of hoping for new experiences and magnification of existent experi-ences a readiness for acceptance of the status quo has to be developed. Physical as well as psycho-logic growth follows a curve which is steep in the first few years of life, and which gradually flat-tens out when maturity is reached and subsequently changes into a decline (29). Mature people are aware of these changes and know that linear gen-eralizations from the past into the future cannot be made. The infantile but chronologically adult personality, however, tends to continue with such expectations, which constitutes the basis of magic and omnipotent thinking. Such an attitude fre-quently impresses the observer as being a sign of youthfulness and optimism, while in effect it con-stitutes inability to discriminate, which then leads to a distortion of reality. In these cases fantasy does not fulfill the function of sublimation or an-ticipation (8) but substitutes for action and there-fore constitutes a defense mechanism.
Dependency
In the infant mastery of reality is achieved either through experimentation, that is, learning through trial and error, or through imitation of parents or other adult persons with whom a significant inter-personal relationship has been established. This latter form of learning compensates for the insuf-ficent strength and experience of the child and en-ables rapid growth, a process which consists of transferring relevant cues and of rewarding the act of imitation (37). If the child had to find out by himself all the aspects of a modern, technical civilization he would have to live thousands of years. While in childhood dependence is instru-mental for reaching maturity, in adulthood the ef-fect of learning through imitation prevents ma-turation and obliterates utilization' of experience gained through learning by trial and error. Per-sistence of this infantile pattern of imitation in adult persons is usually caused by inability to form consistent and clear-cut proprioceptive cues which would enable the individual to proceed on his own. Thus he does not react to signals of an-xiety, anger, or fear; he does not react appropriately to his urge for sex, hunger, or shelter, and he does not know about his needs for membership in a group. Instead, he relies upon cues received from others, which necessitates permanent guidance and support by others. These infantile personalities can live only in close symbiosis with other persons, since they do not possess an identity of their own.
Conscience and Ideals
When the infantile personality reaches a cer-tain level of organization, the suger-ego is char-acterized either by an overbearing conscience and high-pitched ideals, or by weakness or absence of these functions. If the conscience is powerful it dictates in a stereotype manner in terms of good and bad, making operational assessment of reality impossible. Since judgment and experience are not utilized the individual relies upon values and rules which derive either directly from others (overt de-pendence), or which have been internalized (de-pendent upon suger-ego). The naive observer is frequently impressed by the pseudo-maturity dis-played by people with a rigid super-ego. On closer scrutiny it is easy to recognize that ideals are high-pitched and out of proportion to the individual's potentialities, while a restrictive conscience im-pedes free choice of responses and gratification of vital needs. High-pitched ideals result in depres-sion and disappointment, and a strict conscience leads to self-condemnation and appeasement of guilt in terms of self-punishment. Such patients become so dependent upon these impulses arising in the super-ego that they appear to be controlled, driven, and forced to act in a stereotype way. In-stead of using impulses arising in the super-ego as mere warning signals, the moral forces in these in-fantile individuals seem to lead to the establish-ment of an intrapsychic dictatorship which is not felt as an integral part of a person but somehow remains a foreign body and is felt as a burden or pressure. Therefore, identification with groups, movements, ideas, and values becomes difficult; in-stead, destructive and secondary ego-identification with other persons prevails. While ego-identifica-tion is the result of fear or anticipated threat lead-ing to a siding with the more powerful enemy (17) and ultimately leading to its destruction, super-ego identification (15, 29) is the mechanism which enables permanent and solid group identi-fication. Ego identification is instrumental and ancillary in character, while super-ego identifica-tion emphasizes values and goals. In a mature in-dividual, however, all these part functions are in-tegrated and therefore cannot be isolated.
