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INSTITUTION FOR DEFECTIVE DELINQUENTS, WALTER N. THAYER, JR., M. D.
ETHAN A. NEVIN, M. D. CHARLES BERNSTEIN, M. D.
SYRACUSE STATE SCHOOL FOR MENTAL DEFECTIVES,
О. Н. СовВ, М. D.
THE PSYCHIATRIC QUARTERLY
With this number THE PSYCHIATRIC QUARTERLY makes its first appearance on the psychiatric stage; it succeeds the State Hospital Quarterly which has appeared regularly since November, 1915. The change in the publication is due in part to the reorganization of the State departments whereby a new Department of Mental Hygiene has been established to carry on the work previously done by the State Hospital Commission, and the State Commission for Mental Defectives, together with other new functions. The enlargement of the Department necessitated an enlargement of the scope of its official organ as well as the adoption of a more inclusive name. The PSYCHIATRIC QUARTERLY will deal with the whole range of mental disease, mental defect, epilepsy and allied disorders; also with the problems of hospital administration, nursing, occupational therapy, mental clinics, social service, prophylaxis and other mental hygiene activities. Appropriate articles of merit from authors in any part of the country will be welcomed but preference naturally will be given to contributions from psychiatrists in the New York State service.
The minutes of the Quarterly Conference, local news of the State hospitals and institutions and other items of local or transitory interest will hereafter be published in a separate pamphlet to be known as the Supplement to the PSYCHIATRIC QUARTERLY.
The annual subscription price of the QUARTERLY will remain at $2.00, while that of the Supplement will be $1.00.
TABLE OF CONTENTS
ANALYTICAL TREATMENT OF A NEUROTIC REACTION.
A STUDY IN SYMBOLISM
BY LELAND E. HINSIE, M. D.,
NEW YORK STATE PSYCHIATRIC INSTITUTE, WARD'S ISLAND, N. Y.
In the practice of psychoanalysis one encounters a wide variety of pathogenic mental reactions, some of which respond favorably to psychoanalytic treatment, while others at the opposite pole are almost entirely uninfluenced. Between these extremes are all gradations of responses; it is with those patients, who occupy what in the present light of enquiry we may term the highly resistive realm, that we are here particularly concerned. We who deal especially with well established psychotic reactions are able to view the patients' conflicts in their nudity very early in the development of their illness. The conflict is laid bare, the archaic and infantile mechanisms are obvious, yet, no matter how much we may possess of the total life history of the patient, we cannot employ the data in the average case in a therapeutic sense. At first glance we are inclined to believe that the same mechanisms that operate in the complete exposé of the libidinal strivings play an important rôle in what is commonly called resistance. The basis for this is probably to be found in the consideration that there are all variations of dissociation of affect and ideational content, and that therapeutic efficacy is in a large measure dependent upon the degree of dissociation; the chasın, however, does not in itself comprise the sole factor, for it not infrequently happens that an especially wide gap, separating adequate emotional responses from thought content, may eventually be closed in, thereby re-establishing coordinate functioning. If, however, the physician is unable to accomplish this bridging in a satisfactory manner, little improvement in the patient's condition can be hoped for. When a definite splitting has taken place as, for instance, that which occurs in the group classed as schizophrenia, the problem, as we now understand it, is first to reduce the symbolizations to their real meanings and then to cause a fusion of the latter with their proper affective values. When these therapeutic mechanisms are effectively accomplished, the patient can be said to have recovered.
In the schizophrenic group under good cooperation one is generally able to trace the successive steps through which the various components of the psychotic syndrome have passed; the complete history may be unravelled; and still the analyst may be quite frustrated in his efforts to effect a reconciliation of affect and
ideational content. In literature cases have been recorded* in which recovery has been brought about in the face of pronounced dissociation. But, little is understood of the forces that operate in the recovery. Kempf's suggestion, viz., that therapeutic adequacy in schizophrenia is largely dependent upon altruistic transference and the spontaneous wish for insight seems to comprise the most favorable explanation yet advanced.
In psychoanalysis the term transference connotes the capacity of the subject to project his deeply rooted (unconscious) libidinal strivings upon the analyst. The latter thus becomes the imago, by which the unconscious yearnings attain renewal and perpetuation. Transference is, therefore, a resultant of unconscious forces. And resistance has a similar origin. When the analyst strives to lead the libido into consciousness and to unite it with reality, the factors that were responsible for the inversion of the libido come into play as resistance.
There is another source of resistance, one that is built up in consciousness. Both the conscious and unconscious tend to preserve the integrity of the unconscious libido and its constellations. The conscious resistance comprises a defense against the intrusion of reality into the unconscious realm, that harbors the preferred complexes. Speaking of the relationship of transference to resistance, Jelliffe says,' "These relations take the direction of the situation in which all conflicts must be fought out in the territory of the transference, and the transference appears to be the strongest weapon of the resistance, while the intensity and persistence of the transference are effects and expressions of the resistance. The mechanism of the transference is adjusted through leading it back to the preparedness of the libido which has remained in possession of infantile images; the explanation of its rôle in the treatment is successful only if one enters into its relations to the resistance.'
Transference and resistance may exist "at the same time toward the same person" Bleuler terms this coexistence "ambivalence." In borderland psychopathological states both may be strikingly prominent. By borderland we refer here to that large group of psychoneurotic individuals, who possess moderate yet unmistakable evidence of "splitting" of the psyche. We feel that the study of this group might throw some light upon the mechanism operating
* Kempf, Edward J., The Psychoanalytic Treatment of Dementia Præcox. Report of a Case. Psychoanalytic Review, Vol. 6, p. 15.
*Technique of Psychoanalysis, Nervous and Mental Diseases. Monograph Series No. 26: p. 90. * Ibid.