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in the more pronounced schizophrenic states, that we might gain a more comprehensible understanding of the factors tending to induce what is commonly referred to as "lack of insight."
The Case of Henry. A young man, Henry by name, had been troubled from early youth with the fear of death; the fear was prominent in childhood and became intensely accentuated at and beyond the period of puberty, being manifested chiefly in the form of anxiety states during which he felt that complete collapse (death) was imminent. Over a period of years he visited a score of physicians, each of whom made efforts to a greater or lesser extent (more frequently the latter) to solve the nature of his difficulties. From a thorough survey of his attitude toward the host of physicians we could see two outstanding characteristics. In the first place, Henry craved the attention of physicians; during the past 12 years the physician has represented to him the source of omnipotence, the means by which his life could be perpetuated; he had such an undue attachment to members of the medical profession, that the thought of ever encountering a situation in which a physician was not immediately available gave rise to anxiety in a pronounced form. Whenever he was in a distant part of the town in which he did not know any physician, he would stand in front of one's office, imagining the physician was assuring him of the absolute improbability of the panic resulting in death. Henry carried the attachment to the physician to fetish worship, for he always had in his possession some object identified with a physician in particular or with the medical world in general; and the object comprised nothing more or less to Henry than the reincarnation of the medical man's help. He extended the worship into almost every conceivable item in the environment, thus enabling him at a moment's notice to summon the power of the physician to protect him; in Henry's early manhood only the physician himself could wield the magic force over him, but as time passed Henry was embarrassed by the criticism of others that he was totally under the solicitude of doctors, and he therefore began to devise means by which his absolute dependence would be less recognizable. Hence, he eventually acquired a legion of symbolisms; he could almost always find someone who resembled in some slight way at least any one of the many physicians who had "treated" him; a scarf, hair color, voice, carriage, a gesture, etc., etc., ultimately and with much ease were empowered with the attributes of the object with which he originally identified himself. When, for instance, he felt anxious while in a certain neighborhood, he was able at a moment's notice to invoke
the aid of a wide variety of symbols, thereby investing himself almost totally with alleged healing influences. A house of a certain architecture, he imagined, was like that occupied by a physician who had once "assured" him; hence, the house came to have the therapeutic value of the physician; a sign, not necessarily of a physician, placed in a window had the same worth; later, any sign, denoting any calling, a sign of any size, on the ground floor or near the roof, was unqualifiedly endowed with healing power. Again, one of his physicians owned an automobile of a special make; when he left that physician, the same car under any other circumstances sufficed to allay the full development of the anxiety state; finally, all automobiles had the same soothing influence. And the facility of identification went on ad libidum.
Obviously, Henry was utilizing one of the earliest infantile mental mechanisms for the attainment of his ends. By a simple gesture he was able to give to any object any power that he desired. A scarf became a man; more than that it was by magic transformed into a most powerful influence, one that could ward off death; just, as, for instance, a child's toy can respond to any wish of the infantile imaginings. The wish takes priority over everything else.
Before we begin to analyze the connotations of the wish, we want to call attention to another, and contrary, attitude of Henry to the alleged greatness of the physician. We must bear in mind that the physician has been to him only what other environmental factors have been, namely, a symbol by which he could keep alive his deeply-rooted phantasy life. Whenever Henry found an object that might act as a suitable resting place for the complexes that he did not care to exhibit on his own person, he was ready to adore the complexes, as if they were not his own. That this was true was evident to the majority of physicians (of psychiatric training) who saw him, because Henry loved all of them until they began to enquire into the cause of the anxiety states, whereon he rapidly withdrew from treatment. The present physician is the only one who has successfully penetrated his bulwark of symbols. Prior to the beginning of the present investigation, he remained longest with the doctor who prescribed for the symbols and he avoided the doctor who prescribed for the meaning behind the symbols. In this respect he resembled to a large extent the patient with schizophrenic mechanisms, particularly because he failed to recognize the simplest motives that controlled his behavior, even after a thorough analysis gave unmistakable evidence of his underlying trends. He has contributed a large number of signs that point to the unwillingness to relinquish the infantile attachments.
This phase comprises the second part of his ambivalent attitude toward the physician. The fact that he has had such a large num、 ber of physicians, "none of whom has ever understood me," is a compliment to the untiring efforts he has engaged in to prevent the release of the infantile fixation. One cannot believe that "the horrible fear of death" from which, he alleges, he wishes to be free is not after all as troublesome to him as is the relinquishment of the infantile mode of reaction and the adoption of healthy adult behavior, that would necessarily be the result of the abandonment of the infantilism. As long as he could engage the services of physicians who assured him that the fear of death could not in itself induce death, or, in other words, as long as he could survive and still retain the fear, which shorn of its symbolism meant the perpetuation of infantile life, he was as content as could be expected. There is much evidence to show how averse he was to the solution of the symbolism.
For a period of almost two years, while he was under treatment of the present writer, he was so highly resistive that he seldom acquainted the physician with any of his rich dreams life and associational material was revealed in meagre, scattered bits. He repeatedly complained that he was not given the "assurance" that other physicians gave, and he laid special stress on the symbolism. For months treatment remained on an almost purely impersonal basis, for it took that time to convince him of the simplest truths regarding the general employment of symbolic behavior; it is believed that he now understands the universality of symbolism, but, he fails to make any practical application of the knowledge to his own condition. The failure is not due to intelligence itself, for he has an intelligence quotient of 120; moreover, he is a college graduate and has successfully met educational problems of a relatively high order. The difficulty has a wish-fulfilling basis, which is so securely grounded that after more than three years of analysis there still remains as large a gap between the knowledge of himself and the dynamic application of it to his own problems as there was at the beginning. In this sense, at least, he is not at all unlike the schizophrenic patient, about whom we know a great deal, but into whom we are as yet powerless to instill insight.
The wish to retain the infantile union has often been corroborated. Eight years ago he wrote to one of his physicians as follows: "I wish you would have pity toward me, the pity of a father toward his child. How I wish I could feel as I used to when he talked to me! Your kindness and solicitude bolstered me up. I
need one who can talk to me as a good father. If you could only be near me tonight, I would lay my head on you and rest, rest, rest, rest. Pardon me, for I am such a weakling." Eight years later to the present physician he said, he wanted (at the time the letter was written) "the peaceful comfort of just resting in the arms of someone strong and protecting." But, he did not want any investigation made into the nature of his illness. He, therefore, passed from one bosom to another, through a multitude of motherly physicians And the present physician, who acted essentially in a similar capacity, while at the same time being able gradually to link the symbolic behavior with the infantile past, has only recently and indirectly elevated him to the stage of psychological creeping.
At one time during the course of the analysis, when it appeared that he would finally acknowledge a relationship between the symptoms of the neurosis and the infantile unconscious, he resorted to several forms of resistances, the totality of which preserved the integrity of the unconscious. He dreamed that the physician had died. He later said that if the physician died the analysis would cease. Throughout this period of analysis he was very unwilling to continue, maintaining that psychoanalysis was claimed by many to be a fraud and that its postulations were entirely unwarranted. He took the occasion to gather all the material he could to dispute the efficacy of psychological therapy. Indeed, his fervor comprised for a time a new neurosis, through which he gained temporary relief from the old. But it was discouraged, because it was not the type of superimposed neurosis that leads to healthy adaptation. He gave way (in a dream) to his resistances, having been willing "to try the treatment to see if it was any good." The dream was this: "There was a rather mysterious gentleman (a physician presumably), who made me think he was one of those who advertise in magazines. I said to him, 'I'd like to be your assistant; I've always wanted to work with one like you.' It seemed, though, that I had in mind a curiosity to assure myself by first hand knowledge of the absolute truth that such persons are quacks." Henry granted after much deliberation that he held absolutely no brief for psychoanalysis, that he maintained a categorical denial of the value of the practice.
The same trend was present in another dream. "I was riding on a trolley; I had a book, seemingly a text-book, and it was opened at a page on which was described the functioning of the brain. I pulled down the window shade, because the sun was shining on the book. Naturally the type became indistinct, because the light was
shut out." One of Henry's severest tasks, and one from which he usually shrank, was trolley riding. He felt comfortable in the dream; hence, he was well, he said, because he has often repeated that if he could only ride in peace he would be well. Moreover, he had a text-book. The dream occurred shortly after he had been advised by one of his professors that if he concentrated on study he would become well. He was concentrating in the dream; therefore, he was well. But, the text was on the brain and he "shut the light out." In his free associations he pointed out how stubborn he had been to all efforts at understanding his own "brain" functioning. Moreover, he has insisted that the fear can be removed without any probing into his mental (brain) life; and the conscious wish is easily attained in the dream.
One day a physician had told him that epileptic patients do not care to get well, because their unconscious wish to retain the infantile associations assumes priority over the demands of reality; the night of that day Henry dreamed that he had an epileptic convulsion during which "I was striving to overcome my unconsciousness, but I was totally helpless. Surprising enough I was not scared; in fact, I seemed to be at ease." Like many other patients of his type, Henry has often wished that he could ascribe his mental illness to some definite organic changes; during the first few years of the neurosis he begged physicians to examine every organ, especially the heart, for he had invested one organ after another with the libido, that genuinely belonged to the infantile ideational sphere; and he remained with those physicians who alleged to have found an organic cause; temporary abatement of the anxiety was, of course, the result, not of the drugs administered but of the support he received in displacing the affect. A close analogy is seen in the dream material; he was at ease in the knowledge that he had epilepsy. His dream life, in other words, operated to disguise the origin of the neurosis.
Henry's formula for the retention of his neurosis comprised in the main his refusal to reveal the significance of the symbols. After several interviews during which the physician had cited a wealth of evidence taken from Henry's own case material, to show that he was still unduly attached to the mother imago, he refused to acknowledge that his interests in his mother had any special significance. At this time he dreamed that "a doctor had promised to cure me if I revealed all I knew, but he failed." In his associations Henry claimed, as he had frequently done before, that even if his entire psychical career were laid bare, the physician would be