The Psychoanalysis of Symptoms Henry Kellerman PH D Auth

The Psychoanalysis of Symptoms
Henry Kellerman, Ph.D.
The Psychoanalysis
of Symptoms
Henry Kellerman, Ph. D.
Postgraduate Center for Mental Health,
128 East 26 Street,
New York, NY 10016
USA
henrykellerman@earthlink.net
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Preface
Prevailing wisdom in the clinical arena has had it that each psychological symp-
tom is a separate lock requiring its correspondingly unique key. Thus, it has been
thought with respect to symptoms, that there are an infinite number of locks and a
correspondingly infinite number of keys. Further, the psychoanalytic sense of it is
that each symptom needs to be assessed, analyzed, and approached with reference
to the unique experience of the patient and the patient’s history; among other fac-
tors, also in terms of psychosexual conflict, and ego-strength. Given this position,
it also has been felt that no single procedure, or code could be developed to
address all symptoms of all patients as though, as an analogy, one lock and one
key could apply to every symptom.
In this sense, there has been scarcely any attempt to derive a universal code that
would address all symptoms with respect to the formation and structure of the
symptom, regardless of the patient’s particular experience and psychological his-
tory. In this volume, however, with only a few qualifications, I will present a sin-
gle universal code to unlock any and all specifically defined psychological
symptoms. I will present a system and procedure–a blueprint–with which to do it.
One key.
Further, this procedure will be guided entirely by a set of propositions and
axioms regarding each step in the unlocking of any symptom. The only qualifying
conditions to this promise of presenting such a universal key for the unlocking of
“any symptom,” are these:
1. The symptom has not entirely radiated the person in terms of a psychotically
deeply engraved pathology, which can best or even only be alleviated with
medication.
2. The symptom has not been characteristic of the person for the major part of
that person’s life. It is not, in other words a chronic condition.
3. The symptom is not a chronically entrenched somatized one.
4. The symptom is not a function of a physiological problem, an organic brain
syndrome, or genetic anomaly.
5. The symptom is not one of recent onset due to extreme trauma and based upon
a profound sense of helplessness regarding the trauma, in which an implosion
vii
viii Preface
of rage, unconscious though it may have been, has been chaotically scattered as
rage-debris throughout the psyche.
6. The symptom is not a function of a less than normally resilient ego that would
in turn generate a thin stimulus-barrier ultimately resulting in an exaggerated
response to untoward or intense stimuli.
Other than such encrusted, overly ego-susceptible, somatically or organically
based, and deeply etched pathological symptoms, all others are subject to an
unlocking by this one master key.
That there are two classes of symptoms is clinically evident. The class of symp-
toms not easily treated, and quite resistant to psychotherapy, are those that swallow
the person whole so that he or she, in a sense becomes the symptom. In contrast,
the class of symptoms that indeed, is more easily subject to psychotherapy
includes those that remain only as an aspect, an alien facet of the
personality–seemingly outside of the personality.
Alleviation of emotional-psychological symptoms and symptom-cure is what
we want to do. I have long believed that what psychoanalysts and psychothera-
pists accomplish has nothing to do with cure. The notion of cure regarding the
psychoanalytic or psychotherapeutic endeavor misses the point. Life cannot be
cured. The best we can do is to offer the patient the ability to develop tools with
which to struggle, and to struggle better. No more, no less.
However, the only cure we do achieve, is with symptoms. This, despite the fact
that there is no legacy either from Freud or anyone else that details a specific
procedure or blueprint that we can use to proceed, in order to cure those
symptoms that are subject to the talking cure in the same manner, and from a
specific knowledge base, so that no matter the symptom, we can apply this
template, penetrate the symptom, and cure it.
In this volume, as I’ve stated, a blueprint will be presented that forms the
equation necessary to indeed penetrate the symptom and erase it, dissolve it, and
cure it–eliminate it forever.
Organization of the Volume

In Part I, “Theoretical Context,” the theoretical, scientific, and clinical literature
on symptoms, their formation, and structure are considered. In addition, the
symptom-code herein proposed, is presented with respect to its underpinnings,
application, and relation to issues of personality.
In Part II, “The Clinical Casebook: Accessible Symptoms,” examples of the
class of symptoms are presented that can be understood, penetrated, and erased
through the application of the symptom-code and by the talking cure–by
psychotherapy. Such symptoms exist quite apart from the rest of the personality
and are usually, but not always, of recent onset.
In Part III, “The Clinical Casebook: Inaccessible Symptoms,” a variety of
symptoms are presented that can be understood, but which cannot be easily
Preface ix
penetrated or erased through the application of the symptom-code and psychother-

apy. These are inaccessible symptoms of long standing, which have infiltrated the
personality in such a way that the symptom and the person have become indistin-
guishable. Furthermore, as stated, these inaccessible resistive symptoms are those
of organic or genetic origin, or of a chronic somatization, or can reflect a psychot-
ically chronic existence. In addition, as a result of an acute unconscious dispersion
of rage-implosion, usually because of a profound trauma, the symptom may have
been so infused into the fabric of the person’s psyche, that the person’s subjective
experience would make elimination of such a symptom feel tantamount to elimi-
nation of the personality itself. This also includes symptoms that are developed
because of an absence of sufficient ego-resilience in the subject, making for a
particularly exaggerated response to intense stimuli.
In Part IV, “Examining Theoretical Issues of the Symptom-Code,” various
issues are discussed in the treatment of symptoms that need further elaboration,
research, theory, and synthesis, with an eye toward targeting those areas in the
symptom arena that lack sufficient understanding. This sort of discussion is
necessary because it should not be assumed that the arena of symptom cure, or
even symptom understanding, is to date, complete. Save for the symptom-code
presented in this volume, a systematic, ubiquitous approach to the penetration of
the symptom has not been presented in the psychological literature as a cohesive
body of work. Rather, the theory of symptoms, and the theory of the treatment of
symptoms, including that referenced in Freud’s published work, is actually
distributed throughout the entire psychological and psychoanalytic literature, but
only in a fragmentary fashion.
In addition, since the symptom-code presented here is so new, it needs time to
be tested by clinicians as they utilize it to approach the wide variety of symptoms
presented to them by their patients. Along with this need for more scholarly and
clinical work regarding symptom cure, the class of symptoms labeled here as
“inaccessible” has not been codified or attacked with any theoretical system that
would tie various propositions together regarding such symptoms, in any useful
nomological network. Finally, there still does not exist any formulation that syn-
thesizes a general theory for the cure of symptoms here defined as “accessible”
along with those defined as “inaccessible.”
Thus, these four parts of this work will set forth:
1. What has been accomplished to the present, with respect to the scientific and
clinical literature on the understanding of symptom formation and symptom cure;
2. The formulation of a new symptom-code which, when applied, claims the
power of understanding, penetrating, and curing those symptoms that are of
relatively recent duration, and not radiated the psyche by a colossal imploded
rage due to some profound, intractable trauma;
3. The explication of a class of symptoms that can be considered inaccessible
and therefore resistive to cure by the talking method, along with an analysis of
the infrastructure of such symptoms, revealing the essential problem of their
treatment;
x Preface
4. A presentation of theoretical issues detailing the outlines of the entire symptom

domain so that what needs to be done with respect to clinical formulation for a
more comprehensive synthesis of the field, can perhaps be more clearly visible.
It has been more than a decade since I began to formulate the various assump-
tions and propositions that together enabled the crystallization of the series of
axioms to be presented. The entire system is explicated here along with a number
of clinical cases of a wide variety of symptoms, showing how the cure is effected.
Over this past decade I have been teaching the code for symptom cure to
postdoctoral students and professional clinicians, as well as utilizing the symp-
tom-code in the supervision of cases In this present volume I am able to present
the ideas and terms of the symptom-code more comprehensively, bringing to bear
on the subject matter, the relevant psychological literature, and spelling out
symptom cure in technical, systematic, clinical, and scientific terms.
The accessible symptoms referred to throughout this volume are the emo-
tional/psychological one’s patients bring to treatment. They are endless in variety
and sometimes can seem weird, bizarre, often exasperating, and to the patient,
usually embarrassing. These symptoms, subject to psychotherapy, all have at least
two things in common: one, they are experienced by the person as something
strange, even alien; and two, they can all be cured using the same method. One
key for all the locks.
I believe that once patients begin to work with this master key, they themselves
will be able to help the therapist help them. It is hoped that the confusing,
symbolic, other-worldly nature of symptoms will become much more responsive
to the psychotherapeutic touch as a result of therapists and patients, working
together to quickly unlock the symptom. Quickly is the operative term here;
because to do it quickly is important in that it can sometimes take years before the
symptom is cured. And frequently symptoms get cured, not because we necessar-
ily knew how we did it, or even knew how it came about. Rather, because of the
multitude of interactional permutations occurring, sometimes over a period of
years, ultimately, the symptom is dissolved perhaps because of the efficacy of
interpretation, and generally, perhaps because of the overall therapeutic work that
was accomplished. Other than that, we indeed see symptom cure from time to
time, simply by the patient’s flight into health, or by the patient’s acute positive
transference. Nevertheless, these can be considered inadvertent symptom cures, a
side-effect of other variables, and not cures that are the result of a specific knowl-
edge base that the therapist possesses, or the use of a specific procedure that the
therapist systematically implements to accomplish the aim of helping patients
dissolve symptoms.
In formulating the code that reflects the entire blueprint of this symptom curing
procedure, as well as its underlying assumptions and propositions, I have had to
offer alternate equations that recalibrate some basic Freudian precepts. In this
present work it should also be noted that historical and transferential issues that
arise as a result of the process of symptom cure can then be further pursued in the
ongoing unfolding of the patient’s psychotherapy.
Preface xi
I believe it needs to be remembered that a useful theory is one that works best
empirically. Framing it in more universal scientific terms, the most useful, or
most powerful theory, is the one that can explain the widest array of phenomena
with respect to the fewest number of variables.
One master key.
Table of Contents
Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii
Part I: Theoretical Context . . . . . . . . . . . . . . . . . . . . . . 1

1. History of Symptom Psychology . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Other Authors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Anxiety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Repression and the Hint of a Key Emotion
in Symptom Formation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
The Idea of Constant Terms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
2. Underpinnings of the Symptom-Code . . . . . . . . . . . . . . . . . . . . . . . 9
Themes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Defining the Symptom . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
The Wish . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
The Gratified Wish Means Empowerment . . . . . . . . . . . . . . . . . . 13
Anger . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
On the Nature of Basic Emotions . . . . . . . . . . . . . . . . . . . . . . . . . 17
How is Anger Managed? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
3. The Symptom-Code and Its Application . . . . . . . . . . . . . . . . . . . . . 19
Phase 1: Before the Symptom Forms . . . . . . . . . . . . . . . . . . . . . . 19
Phase 2: Formation of the Symptom . . . . . . . . . . . . . . . . . . . . . . . 19
Phase 3: The All-Important Who . . . . . . . . . . . . . . . . . . . . . . . . . 22
Phase 4: The Lifting of the Symptom . . . . . . . . . . . . . . . . . . . . . . 22
Definition of a Symptom Infrastructure . . . . . . . . . . . . . . . . . . . . 23
Implication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
4. On Wishes, Symptoms, and Withdrawal . . . . . . . . . . . . . . . . . . . . . . 25
Positive versus Negative Symptoms . . . . . . . . . . . . . . . . . . . . . . . 25
The Wish and its Relation to Ameliorating and
Exacerbating Symptoms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
xiii
xiv Table of Contents
The Symptom and the State of Withdrawal . . . . . . . . . . . . . . . . . 26

The Line . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Part II: The Clinical Casebook:

Accessible Symptoms . . . . . . . . . . . . . . . . . . . . . . . . . . 29
5. Bottles Under the Bed: A Case of Compulsion . . . . . . . . . . . . . . . . 31
The Initial Consultation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Applying the Symptom-Code . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
Understanding the Symptom . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
6. Holes: A Case of Body Delusion . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
7. Symptoms Based Upon Feelings of Rejection:
Strangling, Sweats, and Death . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
A Case of Intrusive Thoughts of Strangling . . . . . . . . . . . . . . . . . 43
The Initial Consultation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
Applying the Symptom-Code . . . . . . . . . . . . . . . . . . . . . . . . . . 44
Understanding the Symptom . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
A Case of Nighttime Sweats . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
A Case of Obsessive Thoughts of Death . . . . . . . . . . . . . . . . . . . . 49
8. Gazing at Corpses: A Case of Morbid Compulsion . . . . . . . . . . . . . 55
9. Sin of the Priest: A Case of Obsession . . . . . . . . . . . . . . . . . . . . . . . 59
The Intrusive Thought . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
10. Ingenious Regression: A Case of Hallucination . . . . . . . . . . . . . . . . 67
Table of Contents xv
11. Panic on the Bridge: A Case of Selective Agoraphobia . . . . . . . . . . 71

12. “I Can Hardly Move”: A Case of a Three-Day Migraine . . . . . . . . . 77
13. Doubled Over: A Case of Displaced Phallic Obsession . . . . . . . . . . 83
Part III: The Clinical Casebook:

Inaccessible Symptoms . . . . . . . . . . . . . . . . . . . . . . . . . 89
14. The Psychology of Blushing: Involuntary Disclosure
of Success Wishes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
The Symptom-Code and the Infrastructure of Blushing . . . . . . . . 92
A Case of Blushing in a 70-Year-Old Businessman . . . . . . . . . . . 93
A Case of Blushing in a 40-Year-Old Librarian . . . . . . . . . . . . . . 95
A Case of Blushing in a 28-Year-Old Physician . . . . . . . . . . . . . . 97
Commonalities of the Cases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99
15. “No Writing!”: A Case of Delusional Self-Incrimination . . . . . . . . . 101
The Delusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102
16. “I’m Not Going To Work Today”: A Case of Agoraphobia . . . . . . . 107
17. Chaos: A Case of Compulsive Collecting and Hoarding . . . . . . . . . 111
18. Not Thin Enough!: A Case of Anorexia . . . . . . . . . . . . . . . . . . . . . . 115
What Does the Anorectic Symptom Really Say? . . . . . . . . . . . . . 118
19. Dissociative Identity Disorder: A Case of Split Personality . . . . . . . 121
Basic Formation of the Dissociative Identity
Disorder (Split Personality) . . . . . . . . . . . . . . . . . . . . . . . . . . . 123
xvi Table of Contents
20. An Asperger’s Mind: An Examination of the Case of Nobelian

John Forbes Nash, Jr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127
Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128
Asperger’s Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128
The Proposed Deep Structure of Nash’s Schizophrenia . . . . . . . . 130
Dynamic Elements of Nash’s Problem . . . . . . . . . . . . . . . . . . . . . 130
Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137
Part IV: Examining Theoretical Issues

of the Symptom-Code . . . . . . . . . . . . . . . . . . . . . . . . . . 139
21. Acting Out: The First Symptom and the Primacy of Anger or Sex . 141
Is it Anger or Sex? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141
The Primacy of Anger . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 142
The Psychoanalytic Understanding of Acting Out . . . . . . . . . . . . 143
Abridging Traditional Psychoanalytic Understanding
of Symptom Formation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 144
Illustrations with Clinical Vignettes . . . . . . . . . . . . . . . . . . . . . . . 145
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147
22. Symptoms Versus Character Traits: Accessible Versus Inaccessible
Symptoms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149
What, Why, Who, When, Where, and How What Happens? . . . . 150
What Happens? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150
Why Does it Happen? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151
Where Does it Happen? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153
When Does it Happen? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154
Who is the Who? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154
How Does it All Happen? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155
23. The Metamorphosis of Symptoms: The Domain of Wishes
and the Domain of Traits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157
The Class of Character Defenses . . . . . . . . . . . . . . . . . . . . . . . . . 158
The Wish and the Anger . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160
The Migration of Symptoms in the Psyche . . . . . . . . . . . . . . . . . . 161
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162
Coda . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167
Part I
Theoretical Context
Chapter 1
History of Symptom Psychology
The history of psychological symptom formation as a clinical and scientific sub-

ject of interest, is of course, tied to the work of Sigmund Freud. Most of the
elements of the entire anatomy of what is considered a symptom–its constituents,
structure, and its very foundation–is considered throughout Freud’s collected
works, although actually in a fragmentary fashion, located in just about all of his
work, either directly or by implication. From his 1894 paper on the defence neuro-
psychoses (1894/1962), to the Fragment of an Analysis of a Case of Hysteria,
1905/1953), to his papers on Inhibition, Symptoms, and Anxiety, 1926/1959),
wherever one looks, it seems that everything ultimately points toward symptom as
psychopathology. Thus, just about all of Freud’s work, in one way or another, can
be correlated to almost every facet of the subject of symptoms.
A cursory listing of some of the considerations Freud raised, either having
direct relevance to the study of symptoms, or implying important issues in this
study, can easily comprise a separate glossary of Freudian terms and concepts.
The following is only an illustrative sample of this sort of compendium.
Conflict between ego and id; the function of defenses; the special nature of repression; equi-
librium of drives; consciousness versus the unconscious; compromise formations; drive
derivatives and fear and guilt; breakthrough of drives; analogy to a manifest dream; similar-
ity of dreams and symptoms; substitute gratifications; repressed wishes; pleasure and
unpleasure; ego alien material; anxiety; symptoms as a way of removing the ego from
danger; instinctual demand; primary and secondary gain; overdetermindness; helplessness;
unbearable ideas; conversion; symptom precipitators–grief, despair, depression; sexual
wishes and repression; recathexis of object representation; narcissistic satisfaction; castra-
tion fear; energy fortification.
Thus, in Freud’s amalgam of variables bearing on the appearance of symptoms,

their source, purpose, formation, and structure, the above listing is really only a
modest sample of the massive amount of theoretical and clinical material that
Freud brought to bear on the study of symptoms and their treatment.
In distilling the essence of his position and particular understanding of symp-
toms, he proposed that a symptom is part of a solution to a situation that the
person deems to be dangerous. Of course, Freud’s position is that such danger
originates from the person’s own impulses. In his “Fragment of an Analysis of a
3
4 1. History of Symptom Psychology
Case of Hysteria” (1905/1953), he indicated that in the process of the solution to

this dangerous situation, the symptom will form, thus necessarily producing an
impairment of a usual function. In “Inhibition, Symptoms and Anxiety,”
(1926/1959) he stated that then a new phenomenon will appear that has arisen out
of this impairment. This process, he continued, ends in the symptom that has
removed the ego from danger, an end result that has also disguised the person’s
wish (a forbidden wish) as the symptom. It is the conflict between these forbid-
den, (usually sexual) wishes, and corresponding repressive forces, that then,
according to Freud, underlies every neurotic or psychological symptom. In fact,
according to Freud, all symptoms are derived from childhood sexual disturbance.
Finally, with respect to Freud’s salient dimensions of symptoms and symptom
formation, the concept of repression needs to be emphasized. Freud (1936/1961),
stated that: “A symptom arises from an instinctual impulse which has been detri-
mentally affected by repression” (p. 8). The forbidden nature of the impulse that
invites repression, concerns the threat of punishment, the agency of which Freud
initially proposed, was castration anxiety. Repression also needs constant energy
fortification. So, because instincts are continuous, the ego must provide a perma-
nent expenditure of energy to keep these instincts repressed. Then, ultimately, the
manifestation and dynamic operation of the phenomenon of resistance, is what is
generated to protect this repression.
This idea of the use of resistance to protect repression also establishes the psy-
choanalytic definition of acting out, distinguishing this psychoanalytic definition
from that of psychiatry. The psychiatric focus regarding acting out concerns the
behavior of the subject; that is, the person in action. In contrast, the psychoana-
lytic focus of acting out is not primarily about behavior so much as it is about the
attempt the subject makes not to know something. Freud’s observation and
discovery was that repression is what keeps the person from being conscious of
concealed, dangerous impulses or thoughts that he or she is harboring. Further,
Freud’s profound insight with respect to this issue of repression was that the
patient’s resistance assured the sustaining of the repression. Therefore, rather than
knowing or seeing these impulses or thoughts, the person behaves in ways that
motorically symbolize the repressed material. It is in this sense that acting out, in
the context of human history, may be the first ubiquitous symptom–doing, rather
than knowing–the quintessential psychoanalytic definition of acting out.
Freud, in other words, posits that a compromise takes place that neutralizes the
danger of a sexual impulse (the instinct), but then causes the impairment of a
usual function, and in its place there arises the formation of a new phenomenon,
the symptom. Again, the ego is thus removed from danger and the wish becomes
actually gratified as a transformed entity, the symptom. This is an important
point, a discovery of major proportion; to wit, that the symptom is really the wish
realized, albeit in neurotic or perverse form.
This insight of the relationship between the wish and the symptom leads us
inexorably to Freud’s definitive axiom regarding wishes and repression, one that
has the unmistakable ring of psychoanalytic truth; that is, no wish will be denied.
It may be that the psyche is so pervasively governed, so wired, and even fueled by
Other Authors 5
the pleasure principle, that this self-same psyche regards the wish as an impera-
tive, and as such, does an undeniable, almost mathematical dance, a contortion of
sorts, to get the wish represented, gratified– in the extreme form of a seemingly
incomprehensible symptom.
Other Authors
Many other authors have considered symptoms in general terms, restated Freud’s
psychoanalytic position regarding the etiology of symptoms, attempted to further
understand the structure of the symptom, or suggested ways of elucidating vari-
ous specific facets of the symptom or of its formation (Alexander, 1950; Arlow,
1969; Brenner, 1973; Deutsch, 1953; Fenichel, 1945; Greenacre, 1958; Josephs,
1992; Kellerman, 1987; Luborsky, 1996; Rangell, 1959; and Seligman, 1975).
Brenner (1973) validated Freud by pointing to the importance of defense as a
way of keeping an equilibrium in the psyche. This equilibrium acts as an ego adap-
tation to the stress of the drives. The symptom, therefore, is seen to be a result of a
failure of ego defenses. Brenner wrote that as the conflict between the ego and id
intensifies, defenses of identification, regression, and sublimation, are utilized to
further control the drives. Yet, when drives threaten to break through–to emerge into
consciousness–and correspondingly, when defenses are deemed insufficient to sus-
tain an equilibrium of the psyche, the ego then struggles to create a compromise.
This compromise, of course, is the psychoneurotic symptom. Brenner further
concurred with Freud by noticing the similarity of the symptom to the manifest
dream; that is, the descriptive story line of the dream. As such, and just as in a
dream, a wish on the part of the subject is of primary importance in the momentum
toward the formation of the actual dream, just as the wish is of primary importance
in the formation of the symptom. In order to be understood, the manifest dream
must be unfolded into its latent products through an analysis of the dream mecha-
nisms of condensation, symbolization, displacement, and secondary elaboration. So
too, is the implication that the symptom needs to be unfolded by a process that
utilizes mechanisms that have psychologically evolved to address the intrinsic
structure of the symptom. For example, in the dream, these dream mechanisms are
considered to do the following: two or more elements are condensed into one, hence
condensation; one thing can represent another, hence symbolization; one thing can
be transposed to another, hence displacement; and, elaborations can be made that
coalesce the various and sundry sense impressions, images, thoughts, and feelings,
into a more coherent story, hence secondary elaboration.
The Freudian notion of the parallel between the manifest dream and the psy-
choneurotic symptom begs to be compared in the same manner. What are the
mechanisms that are brought to bear on the Freudian precept of the ego-id con-
flict where the person’s psychological experience was incubated in the first place,
resulting in the appearance of the symptom? The question arises as to whether
such symptom mechanisms may be identified and defined so that an X ray of the
symptom as constituted, showing its structure, the location of the wish, how the
wish is transformed into the symptom, and so on, could be developed. This would
comprise an analysis of the infrastructure of the symptom, and, in essence, would
constitute the psychoanalysis of symptoms.
Identifying the wish is of central importance with respect to this X ray of the
psyche. Brenner (1973), stated:
As seen from the side of the id, a psychoneurotic symptom is a substitute gratification
for otherwise repressed wishes. As seen from the side of the ego, it is an eruption into
consciousness of dangerous and unwanted wishes whose gratification can be only partly
checked or prevented, but it is at least preferable to, and less pleasurable than, the emer-
gence of those wishes in their original form. (p. 189).
In this sense, thus far in the theoretical investigation of the structure of the
symptom, we can see that the wish, defense mechanisms, and instinctual drives
form a primary Freudian focus in understanding how the symptom is formed.
Then, by way of extrapolation, we may wonder whether it would be possible,
through a series of axioms, to know how to systematically unravel the symptom,
dissolve it, or, even hold it in abeyance, so that we may reconstitute the original
wish that the symptom is ostensibly representing as well as concealing. In doing
this unraveling, the issue of anxiety as it relates to symptom formation needs to be
examined. In addition, it is proposed here that the assumption of repressed wishes
as unpleasurable products of the psyche may need to be reexamined.
Anxiety
It should be remembered that from a Freudian psychoanalytic perspective (Freud,
1905/1953), the symptom derives from a series of events, a process, that is taking
place outside of the ego, so that in its formation, the symptom removes the ego
from danger. Freud posited that the ego becomes more and more helpless in the
face of increasing instinctual demand. A point to be discussed later concerns
the issue of anxiety itself as a symptom and what this implies. Regarding the
importance or place of anxiety in symptom formation, Luborsky (1996) stated
that anxiety is the original reaction to helplessness. The symptom then becomes
the first way to cope with this helplessness.
The entire issue of helplessness and anxiety, is of special importance in under-
standing symptom formation, and Luborsky’s reference to it permits us to include
issues of helplessness and anxiety to the expanding list of salient concepts that
will need even further elaboration to enable us to penetrate the symptom. Such a
list would now include: the wish; defense mechanisms; instinctual drives; anxi-
ety; and, helplessness. In fact, Luborsky stated: “Wherever symptoms appear,
helplessness appears before it; whenever helplessness has appeared, symptoms
occasionally follow it” (p. 370). Luborsky also stated: . . . . .“after the symptom
appears degree of helplessness and of anxiety lessens.”
As proposed, and whether intended or not, Luborsky’s formulations are basi-
cally framed as axioms. Luborsky continued to assess the relationship between
Repression and the Hint of a Key Emotion in Symptom Formation 7
anxiety and symptoms by positing that with the symptom present, anxiety is
better bound and thus yields a primary gain for the subject. The subject, however,
also attracts help from others and thereby creates a secondary gain. The case is
also made by Luborsky that, “signal anxiety exists before the symptom appears in
an amount just sufficient to announce that a danger situation is about to appear”
(p.369). On the face of it, it would also seem that anxiety and helplessness are
related, and that they are related in the overall puzzle of symptom formation and
possibly by implication, symptom cure.
The helplessness variable is also referred to by Engel and Schmale (1967), who
point to what they call a “giving-up/given-up” complex. This is a nonspecific
presymptomatic state. It contains a cluster of tendencies and characteristics
including: a lessening of control and a lessening of a sense of security, helpless-
ness and hopelessness, less certainty of one’s perceptions of the environment and
of past experience, and a clouding of differentiation between past and future.
Seligman (1975), concurred, insofar as negative events lead to pessimism in the
subject and then to vulnerability to symptoms, especially to the increase of
depression. Seligman called it “learned helplessness.” The extreme form of such
helplessness is posited in an early book by Goldstein (1939), who discussed cata-
strophic behavior as a prelude to substitute reactions such as symptoms.
Repression and the Hint of a Key Emotion

in Symptom Formation
With respect to conversion reactions (conventionally referred to as hysterical
reactions or hysteria), Freud (1894/1962) proposed that in hysteria, the unbear-
able idea is obscured and minimized by the amount of excitation attached to it,
and then the idea is translated into some bodily language, or bodily form of
expression. Freud called this process, conversion. Fenichel (1945) also referred
to conversions. He indicated that the turning of reality to fantasy was a precursor
to conversions. Here again, repression seems to play a key role insofar as the turn-
ing of reality into fantasy constitutes a withdrawal and implies a repressive
process at work, necessary in the formation of a symptom.
Parenthetically, this turning away from reality also suggests that the individual
was unable to directly or consciously confront some forbidden wish or emotion.
If it was an emotion that was avoided, which one was it? Further, which emotion
is most frequently avoided, and avoided specifically with respect to confronta-
tion? Is it always, or usually, some sexual reference as Freud might have
proposed? Is it anxiety? So far as symptom formation is concerned, it will be pro-
posed here that Freud’s sexual repression is only an apparent culprit implicated in
the understanding of the role of impulse and instinct on the one hand, and repres-
sion on the other. However, where repression is concerned, it will be further
proposed that an emotion or instinct, other than sexual, is the actual culprit.
We cannot guess what any given wish in any person might be, because there
may be an indeterminate number of literal or concrete wishes in humanity’s
psyche. Thus, there is probably not a universal wish that could be identified as
pivotal in all symptom formation. With respect to emotion, however, there are
only a limited number of basic emotions that might be implicated in all symptom
formation–an emotion other than sexuality–that may be the actual culprit.
Assuming this as a possibility, is that emotion love, fear, acceptance, disgust,
guilt, anger, joy, anxiety, or sorrow? In this volume I shall identify which it is:
One thing is quite certain–it is not sexuality or libido–repressed or not.
The Idea of Constant Terms

The point here is that constant terms exist in the symptom equation, the application
of which, I propose, will lead to the unfolding of the symptom. It is hypothesized
that there is, in this particular conception, one primary emotion that is identified as
a constant term in this equation. In Freud’s view, the ubiquitous wish is another
such constant. Freud proposed that conversion is employed to express forbidden
wishes (sexual), which again, in his view, is the true purpose of all symptoms. And
the essence of conversion consists of displacing energy from the psyche to the
body. In this sense, the derivatives of forbidden impulses are expressed in a dis-
torted manner–in other words, in the manner of symptoms. The symptom, then can
be considered a distorted product of the psyche. There are many synonyms of “dis-
torted,” at least two of which are immediately apparent: neurotic, and perverse.
The attempts at various theoretical refinements of what has been understood as the
underpinning to symptom formation cited by authors referred to above, can also
apply to the proposal by Luborsky (1964, 1996), in his symptom context method.
Luborsky studied what he refers to as symptoms such as forgetting, that occur during
any given single psychoanalytic session. Momentary forgetting during a session is
seen by Luborsky to be the result of a particular thought about which the person feels
anxious and helpless. A symptom then appears to help a person cope with these
uncomfortable feelings. Ferenczi (1912/1950), was also interested in symptoms that
occurred during a session and analyzed what he called “transient symptoms.”
Both Ferenczi and Luborsky wanted to understand the context in which the
symptom occurs–in Luborsky’s case, the forgetting during a session. The question
becomes whether the forgetting is actually a symptom. A tentative answer might be
that in Luborsky’s view of symptoms, if the forgetting is not remediable, then a
symptom appeared primarily because the patient was helpless to recall the memory
or thought. The helplessness then promoted a chain of events leading to the defeat
of the effort to consciously capture the wish; that is, to recall the thought. However,
if the patient is still trying to recall whatever it is, so that the wish is not relinquished
and therefore helplessness has still not gained the ascendancy, then the promotion
of that chain of events culminating in a symptom, would not be joined.
In this respect, with regard to the wish and helplessness, in the following I will
suggest a new way of understanding the psychoanalysis of symptoms and ulti-
mately to present a complement of axioms and clinical cases where these rules
are followed. This system will demonstrate that where applied, the use of these
axioms can lead to the efficient dissolution of the symptom–its cure.
Chapter 2
Underpinnings of the Symptom Code
Themes
The capsule review in the previous chapter of the psychoanalytic concepts
involved in symptom formation reveals several components in the construction
and organization of symptoms that will now be further considered. The focus here
will be to present a series of axioms or rules regarding the symptom and the vari-
ous psychological principles embracing it, so that in the end, by understanding
these principles, and by utilizing the rules or axioms, a practitioner would be able
to systematically penetrate the conundrum of the symptom, unfold it, and cure it.
Of course, the psychoanalytic endeavor generally, is not about cure, it is only,
as noted in the Preface, about struggle. The only curing we do however, is the
curing of symptoms, despite the fact that no one has ever established any system-
atic way of doing it. In fact, there is an absence of any systematic approach to
understanding symptoms, as for example, in the absence of any course work
either in undergraduate, graduate, or even postgraduate curricula entitled “The
Psychoanalysis of Symptoms,” or “The Psychology of Symptoms.” The issue of
symptoms is usually a secondary consideration in courses on psychopathology,
or abnormal psychology. Furthermore, the nature of our theoretical repository
sources regarding an approach to symptom cure is similarly quite fragmentary. It
seems that the symptom is seen as derivative of something else, and in psychoan-
alytic education is given secondary status to a focus on the patient’s psychosexual
history, transference, resistance, neurosis, and characterological issues, that are of
primary psychoanalytic interest. This, despite the vast amount of material on
symptoms throughout Freud’s written work, as well as a considerable literature
on symptoms within psychological, psychoanalytic, and psychiatric scholarship.
It is in this sense that the focus in psychoanalysis is on process and not specifi-
cally on cure.
As noted above, through psychoanalysis, people learn to struggle better. There
is no such thing as eliminating anxiety. It is the pleasure principle that governs, so
anxiety becomes a fact of life. The pleasure principle is the fount from which every
symptom is derived. The wish for the complete absence of tension defines both the
pleasure principle and the death instinct. As a matter of fact, Freud’s notion of a
9
10 2. Underpinnings of the Symptom Code
death instinct is primarily based upon the inexorable desire to erase tension. Thus,
with respect to both the pleasure principle and the so-called death instinct, the
symptom becomes a means to manage the presence of tension–albeit neurotically
expressed tension. In addition, the wish is the steady-state product of the pleasure
principle, and reflects its stasis. In daily life, it is the wish that is most often
thwarted. Thus, it is a look at the thwarted wish–this ever present force in all
human affairs, that begins our journey into the heart of the symptom.
Luborsky (1996), is correct, each symptom, no matter how simple, complex, or
seemingly bizarre, has a context. It is proposed here that it is necessary to con-
sider both the context as well as the source of the symptom in order to begin to
understand the underpinnings of the problem. The problem, of course, concerns
the etiology of the symptom as it relates to symptom cure. In fact, it is proposed
here that the order of importance, chronologically, in the etiology of the symp-
tom, needs to consider source first, then context.
The source is the pleasure principle, and its chief representative in all human
desire and human affairs is the wish. It is the wish that is at the bottom of all
symptom formation. However, before the wish is considered, it is necessary to
define what we mean by a symptom.
Defining the Symptom

Here, of course, we are concerned with an emotional-psychological symptom:
“emotional,” because a major specific emotion is involved in all symptom forma-
tion; “psychological,” because a dynamic involving defensive operations such as
resistance, and specifically, repression, act to enable the existence of the symp-
tom, and in addition, the same mechanisms that operate in dream formation–-
symbolization, condensation, and displacement–operate again, also in the process
that enables the symptom to exist. Only the mechanism known as secondary elab-
oration is absent in the formation of the symptom. This is so because it is
precisely the secondary elaboration–the logic and coherence to the original story–
that the subject needed erased, and in fact, was erased by repression. In this way
the subject remains in the dark about what it is that the symptom means. Thus, it
could be said that with respect to analogy, the symptom can be located some-
where between the manifest and the latent dream.
There is no need for logic in the symptom. In this sense, the symptom has a
certain kinship with, and is more similar to the latent dream–that amalgam, in the
unconscious, of amorphous bombardment of stimuli, reflecting conflicts, fixa-
tions, and hungers. Along with this, the symptom is also similar to the manifest
dream insofar as the wish is symbolically cohered into a tightly knit entity (the
symptom) and is thus congealed, more like the manifest, and less like the latent
dream.
Luborsky (1996) contributed to the understanding of the formation of symp-
toms, again, by insisting that the symptom has a context. However, both the
immediate context in which the symptom is born, as well as the motive source of
Defining the Symptom 11
the symptom, need to be considered in order to develop a complete picture of the

formation of the symptom and its meaning. In fact, in the order of importance,
again chronologically, in the etiology of the symptom, the motive source of the
symptom needs to be appreciated first, so as to make sense out of the meaning of
the immediate context of the symptom. The source, of course, is the pleasure
principle, and as stated, its chief representative in all human desire and human
affairs, is the wish. It is the wish that is at the bottom of all symptom formation.
At least three elements comprise the definition of a symptom. All are ulti-
mately experienced by the subject, so that these elements are existential.
1. A symptom is an involuntary reaction that the person experiences. This means
that something happens that is outside the person’s control–that can’t at all be
voluntarily controlled.
2. A symptom is an ego-alien reaction. This means that the symptom reaction
feels different from anything else in the personality, as though it has been pro-
duced by a force outside of the personality–the person, feels possessed.
3. A symptom is a tyrannical reaction within the personality. This means, that
whether the subject likes it or not, the symptom controls the subject and not the
other way around.
Furthermore, a distinction needs to be made between those symptoms that can
be cured through the talking method, and those that resist it. In the former, the
emotion that is repressed remains cohered within the repression, and within the
repression the image of the symptom context also remains intact. In other words,
in the psyche, in the unconscious, the entire configuration of the symptom retains
its integrity and becomes as aspect of the personality. In such a case, the key
implicated emotion has not imploded, and thus this emotion has not strewn its
debris throughout the psyche thereby infecting the entire personality with its radi-
ating pathology.
The symptom that resists cure through the talking method is one in which the
specific pathological emotion has indeed imploded, and the person’s psyche, per-
sonality, character structure, chemistry, and nervous system, has been entirely
permeated, thereby contaminating his or her inner psychological and emotional
life in a way that can be considered a basic usurpation of the personality. It is fur-
ther proposed, that in the unconscious, the symptom that resists cure is also one in
which the internalized image– the memory of the symptom context–is no longer in
tact, and especially, no longer connected to the repressed emotion.
In this sense, it will be predicted that because the connection of the stimulus
(symptom context) to the specific and ubiquitous emotion that was repressed,
becomes disconnected, that the symptom will no longer be merely an aspect or a
facet of the personality. Rather, such a symptom swallows the personality, as it
were, so that the symptom becomes the personality and not just an aspect of it. In
this latter condition, the only seeming cure for the symptom is a longer term treat-
ment and the likely use of medication. How and why this disconnect of the symp-
tom context to the key repressed specific emotion causes such a catastrophic
reaction will be discussed later.
To continue with this image of pathological debris infiltrating and permeating

the person’s entire inner life, a useful metaphor for what medications actually do
might be to imagine that they begin to surround this so-called debris, and further,
begin to collect, condense, congeal, and therefore contain it, until the person is
free of contamination. Within this latter chronically encrusted and sometimes
psychotic symptom condition, either with the ingestion of medicine along with a
longer term treatment, the symptom will possibly abate.
In contrast, examples of symptoms that can be approached successfully through
psychotherapy, are those that do not swallow the person whole. Such symptoms
remain a part of the person that the person recognizes as troublesome or alien and
outside of personal control, but which generally can be compartmentalized and at
least managed, to some appreciable extent, even if not always adaptively. For
example, if it is an acrophobic symptom, the person can avoid heights; if it is an
agoraphobic symptom the person may be able to avoid crowds, or limit one’s
forays to the outside. One of the main points in defining the term symptom, is to
understand that the symptom is the end result of a series of events that begins with
the consideration of a wish.
The Wish
As the chief representative of the pleasure principle, the wish is the most perva-
sive, permeating force within the personality. The problem is that in life there
are too many variables that are not within anyone’s complete or sometimes,
even partial control. The upshot of such meager control of wishes is that every-
one’s daily life is continually replete with thwarted wishes, sometimes big,
sometimes small. If wishes are not fully thwarted, then they are perhaps only
partially blocked. Or, whenever the wish is indeed realized, then frequently it is
not realized to the fullest measure – and even when the wish is realized to the
fullest measure, this frequently takes place not exactly when it is wanted. Thus,
despite the fact that we are a wish-soaked species, on an earth of wish soaked-
creatures, the irony is that wishes are usually in a state of incompleteness – their
benign form, in a state of delay; in its severe form, in a deprived, fully thwarted
state.
In addition, most people find it difficult to make distinctions between important
and unimportant wishes. All wishes are treated as being more or less equally
important – no less, and urgent. Apparently, there are no small wishes in the psy-
che. With many people, the slightest frustration of a wish – minor though the wish
may be – creates the same disempowerment that the frustration of a major wish
does. Hence, the thwarting of wishes in a person can be seen to occupy an inordi-
nate amount of psychological concern.
On a practical level, the definition of civilized living, or of civilization itself,
perhaps concerns the issue of how to survive, and survive happily, in the context
of daily experience in which only simple wishes are really ever met with effi-
ciency; for example, to turn on the hot water and have it be hot–wish gratified.
The Gratified Wish Means Empowerment 13
But to wish that your request for a substantial raise in salary will be efficiently
met, can usually mean disappointment.
The Gratified Wish Means Empowerment

Wishes mean that one gets a wish gratified and achieves mastery, then the person
feels empowered. When the wish is thwarted then the person is disappointed and
feels disempowered, or as Freud (1926/1959), Luborsky (1996), and Seligman,
(1975) noted, feels helpless. Apparently, in the psychological literature, and for
all intents and purposes, helplessness and disempowerment are terms that may be
used interchangeably.
Thus, because wishes are in such profusion, and because such wishes are most
frequently thwarted, then the issue of disempowerment becomes essential in the
understanding of the connection of wish to symptom. Here again, it is important to
remember Freud’s brilliant insight; that is, no wish will be denied. This insight was
based upon Freud’s proposition that dreams are wish fulfillments (Freud,
1900/1953a, pp.122–133). Arlow and Brenner (1964), indicate that Freud’s propo-
sition refers to unconscious wishes. Thus, we now necessarily know that in order
for the wish not to be denied, something psychological has to happen; that is, in the
face of reality where most wishes are in fact denied, then some psychological
mechanism will need to be applied so that the wish will not be denied. And accord-
ing to Freud, this psychological mechanism is repression-a force exerted on the
effect of the thwarted wish, so that ultimately the symptom will appear. The symp-
tom will be the wish in a new form, albeit a neurotic, or perverse one.
In this sense of concealing the effect or emotional reaction to the thwarted
wish, repression is implicated, and becomes indispensable to the process of
translating the wish into the symptom. Repression emerges as a chief defensive
function because it is able to distort, distract, and otherwise dislocate the pre-
sumed instinctual impulse, and in this way, any threat of punishment for having
such impulses is out of awareness and thus neutralized. Of course, in the history
of psychoanalysis, this instinctual impulse is usually defined as libido.
Typical psychoanalytic understanding of this issue of repression of the wish
(the sexual impulse), as a foundation of the formation of the symptom, is a con-
ventional Freudian postulate. Suffice it to say, the important issue here concerns
whether the pivotal repression involving wishes and symptoms, always or even
ever, specifically involves repression of sexual impulses. Of course such a ques-
tion becomes heretical; is it the sexual repression or is it the issue of the thwarted
wish and what the thwarted wish produces–its emotional product–that becomes
crucial in the evocation of the defense of repression that then leads to the subse-
quent ignition of the symptom? Is a sexual impulse always or even ever, the result
of a thwarted wish? This is a crucial question because when the wish is thwarted,
no one is really ever happy. When the wish is thwarted, everyone is distressed,
disturbed, disappointed, and dissatisfied. And this seemingly logical conclusion
of thwarted wishes producing distress, perhaps reveals what might be considered
the actual emotional culprit in the formation of symptoms. That is to say, when
the wish is thwarted, the person is angry. This raises the second question that
asks: Given the assumption that everyone is angry because of thwarted wishes,
then why is everyone angry at thwarted wishes?
Anger
The answer to this question regarding the experience of anger to thwarted wishes,
is that thwarted wishes generate feelings of disempowerment, of helplessness.
Thus, it is evident one might say, on the face of it, that even in the thwarting of
sexual wishes (sexual impulses), disempowerment and anger will be evoked. And
to Freud’s axiom that no wish will be denied, we add an axiom of our own: Anger,
or anger as a sample emotion of the aggressive drive, is the emotional reflex that
has evolved in evolution to address each and every incident of disempowerment.
The rationale for this axiom concerns the natural equilibrium all people seek.
This equilibrium concerns the issue of mastery over the immediate environment.
We want to be empowered! It feels good. Thus, when we feel disempowered, we
get angry. The question is why?
Anger is an attack emotion, and by nature, it is not shy. The essence, or we
might say, the personality of anger can be understood by the presence of a cluster
of traits that characterize its nature-a kind of personality profile of anger consisting
of an attack proclivity, an explosive potential, an aggressive drive, a confronta-
tional inclination, and an entitled frame of mind. Furthermore, and parenthetically,
these traits are all reactions to feelings of disempowerment, helplessness, or even
dependency. Of course, dependency is a special form of disempowerment or help-
lessness. For example, adolescent rebellion after all those years of dependency,
makes more sense when seen through this particular lens of dependency incubat-
ing anger. Clinically, the hard-core psychological principle is that dependency
breeds rage–all the time and in every person. Disempowerment and helplessness
also breed rage, which is the high intensity level of anger. And here is the logic and
answer to why disempowerment generates anger: To feel angry is to regain the
ascendancy and to feel empowered when one feels particularly disempowered.
And at times when there is no other way to find some empowerment, anger will be
the reflex in response to the disempowered condition because for that moment it
will be the only way to feel, at least minimally, reempowered.
Yes, anger is an empowerment, and this brings us back to the wish. In light of
the psychology of disempowerment leading to anger, the implication for a theo-
retical gradient of anger reaction, reveals itself. For example, even though in the
psyche all wishes are major, nevertheless, there exists an implicit “thwarting-
index” so that when a person’s wish is thwarted a little, then the person, in all
likelihood, generates a low level of anger, perhaps at the level of annoyance.
When the thwarted wish is experienced as moderate, then it could be predicted
that the person will generate a medium level of anger. However, when the wish is
very important to the person and then subsequently thwarted, the anger will be
Anger 15
more intense and will, in all probability, be generated as rage or fury–sometimes

conscious, sometimes not.
In a practical sense, the problem that emerges here concerns this psychological
phenomenon regarding the insignificant extent to which people distinguish
between major and minor wishes. The interesting psychological fact, of course, is
that most people do not distinguish between major and minor wishes so that, in
effect, every wish becomes important. “I want what I want when I want it,” is then
the operative condition, a result that implicates emotions of anger and rage as
most commonplace in everyday life.
With so many people trying to manage such a great amount of disappointment,
dissatisfaction, and disempowerment to thwarted wishes, and then reacting with a
corresponding ratio of anger and rage to such disempowerment, it is no wonder
that the lexicon for anger comprises the largest glossary of terms, in contrast to any
other emotion in the human emotion dictionary. For example, the general terms of
stress or anxiety and their wider and deeper meaning can be illuminated if such
terms are understood to be oblique references to suppressed or repressed anger at
conditions that place the person under pressure so that satisfaction of wishes
becomes unlikely, or probably unlikely, or just out of reach, or too much to hope
for. The earlier issue regarding anxiety as a possible symptom itself, may now sug-
gest that anxiety could actually be a radiating effect of what is below–repressed
anger! Thus, the lexicon for anger can contain terms such as upset, or even bored.
Upset is more easily understood; when something is really upsetting, is the person
happy? No, the person is angry but doesn’t want to face it. When someone is
bored, she or he feels trapped in a tedious situation, but because it may not be
socially desirable to be angry in such a situation, the conscious reaction is to only
feel bored.
So which is the road to the repressive process leading to the formation of the
symptom–the sexual frustration, that is to say, pent-up libido, or the anger regarding
disempowerment? Which is the culprit – sex or anger? They’re not the same. The
answer is surprising, given the century-old reliance on the psychoanalytic precept
of sexual repression as more or less, the insidious and pervasive culprit in symptom
formation, and for all intents and purposes, in all of psychopathology as well.
The resounding answer is: Anger is the culprit. More specifically, repressed
anger is the culprit. In order for there to be a symptom, the anger must be
repressed. Freud was the first to enunciate the general principle regarding this
process of repression, and just about all other theoreticians have echoed that
insight or discovery. The discovery, the general principle, was that in order for
there to be a symptom, a repression of the instinctual impulse, understood to the
present time to be sexual repression, was the constant in the theoretical under-
standing of symptom formation.
Theoretically, repression was always indispensable to the process of how the
wish transforms into the symptom. The question raised here is only about whether
the instinctual impulse is sex or anger. Nevertheless, repression emerges as a chief
defensive function in this transformation of the wish to the symptom. This is so
because, as stated earlier, according to accepted psychoanalytic understanding,
repression is able to redirect the instinctual impulse thus neutralizing threat of

punishment for having such impulses. Although, historically, these impulses have
been accepted as sexual in nature, it is hereby proposed that the identification
of such impulses as sexual, is seemingly, inaccurate. A new principle is here sug-
gested, as follows:
In the psychoanalytic theoretical network, the attribution of the sexual instinct
as crucial to symptom formation now needs to be replaced by the anger response
as the true instrumentality, the actual core factor, in the transformation of the
wish into the symptom.
It is proposed therefore, that the instinctual impulse implicated in the whole
psychoanalytic symptom process is anger not sex or the sexual impulse, or even
infantile sexuality, whereby according to Freud, symptoms occur because when
repression fails in adult life, then infantile sexual impulses erupt out of such
repression. Yes, it is true that a symptom can be cured by following sexual inhibi-
tion directly to disempowerment. But a sexual thwarted wish is no different from
any other thwarted wish and leads to feelings of disempowerment, which will
always generate anger. It is not the analysis of the repressed sexuality that will
cure the symptom. Rather, it is only the analysis of repressed anger toward the
who, toward the targeted object, the intended other person, that can ever realize
the cure.
Again, it is proposed here that it is only the anger that accompanies the wish
into repression, into the unconscious. And so long as the anger remains uncon-
scious, and especially remains unconscious with respect to the memory of the
original object–the who toward whom the anger was originally directed–the wish
in the form of the symptom will sustain itself in this perverse or neurotic form, as
a symptom.
In a related observation, Rangell (1959), posits that symptoms can reflect
either libidinal or aggressive impulses. In addition, symptoms indicate changes in
physical function symbolically seen in expressive body language and repressed
instinctual impulses. It is interesting to note that in this definition, Rangell identi-
fies either libidinal or aggressive drives as possible responsible variables in
symptom formation; the operative terms being either, and or. This is important to
note because the aggressive or anger impulse is frequently forgotten, under-
played, or even ignored by psychoanalytic theoreticians in favor of libido.
Interestingly, release of anger is also pleasurable in the sense of the release from
frustration. It is an expostulation, and as such shares with libido as well as with
the wish, some commonality with respect to reflecting imperatives of the pleasure
principle.
The blatant fact is that, concerning symptom cure, anger seems to be the miss-
ing emotion in the psychoanalytic theoretical landscape. Further, the emotion of
anger is one of the few universal terms, along with the wish, repression, and the
memory of the symptom-context, which I propose are the staples of the symptom
cure-equation. I believe the truth of this formulation will become more apparent
in the scientific analysis and clinical explication of the structure of the symptom
and its cure, as the analysis in this book proceeds.
How is Anger Managed? 17
On the Nature of Basic Emotions

The basic nature of emotion (Plutchik, 1980, 1994), is another way of thinking
about the propensity for the reflexive nature of emotions. In addition, the work by
Kellerman (1979, 1980, 1983, 1990), implies that basic emotions also can be
characterized by referring to the personality of the emotion. This consideration of
the nature of basic emotions is important to include here because our focus on the
emotion of anger invites more investigation into understanding the infrastructure
of emotion generally.
The relevant factor of any basic emotion with respect to its “personality,” concerns
its basic tropism–that is to say, what it wants, or what it wants to do. For example, the
basic nature of the emotion, fear, propels the person to flee. Fear, at its most basic
reductionistic self, knows no other guiding principle, no other command, impulse,
inclination, or dispositional tendency but to flee. Of course there are secondary, more
complex social factors, which when brought to bear on the presence of fear, are able
to modify, or alter the fleeing. Nevertheless, without these qualifiers, the basic nature
of fear itself is simply to cause the person experiencing it to flee.
Basic emotions, therefore, it might be said, although developed in a social
context, can be seen to be not of this social world. To underscore the point, to
exaggerate it, it may be imagined that basic emotions exist in their basic raw state,
outside civilization and outside socialization. They obey only what feels good to
the person and are only based upon the imperative of the pleasure principle. Fear,
feels good when the action of successful fleeing is implemented, and feels bad,
when the possibility of fleeing is blocked.
The same is true of all other basic emotions. Anger is another example. Again,
anger knows no civilization. Anger, seen either as a basic emotion or as a repre-
sentative of a basic drive, causes the person to want to attack! It feels good if one
can attack, and feels not so good if the basic need to express anger by attacking, is
blocked. When anger can be expressed with respect to satisfying its basic impulse
of attack, then again it can be said that the imperative of the pleasure principle has
been realized. Parenthetically, I have stated elsewhere (Kellerman,1979), that
because of social and psychological injunctions against confrontational aggres-
sion, anger is more likely repressed than any other emotion.
It is necessary to set forth this notion of the personality disposition of any basic
emotion in order to further appreciate the process involved in the unlocking and
curing of symptoms. This is true especially since the emotion of anger, it is pro-
posed, plays an indispensable role in the formation of the symptom, and is one of
the essential elements in the basic code of symptom formation.
How is Anger Managed?

When repression is not invoked and anger is directly expressed, there can be no
symptom. It is only when anger is managed through repression that a transform-
ing medium is created out of which a symptom forms. Most frequently, however,
when a person experiencing a thwarted wish feels disempowered, and then as a

result becomes angry, and cannot for whatever reason express the anger or even
know it is there, it is then that such anger is captured by repressive forces of the
personality. This entire process can occur in a fraction of a moment, so that the
presence of the anger may never reach consciousness and therefore remains
entirely outside of the person’s awareness.
This reflexive process includes the anger, joined by the thwarted wish, and
through repression becomes a translated product in the unconscious. This process
of translation is embraced at the beginning with a thwarted wish, and at the end
with a symptom. It is wish to symptom; that is, the anger remains unconscious
and the wish is translated and surfaces as a symptom. What this means is that the
anger remains in the repressive unconscious repository of the psyche and sustains
the translated wish as symptom. It is as if the anger keeps the furnace stoked, so
that the wish as symptom is continually lit.
The above comprises a brief sketch of the first phase of the symptom process
with respect mostly to the underpinnings, the assumptions upon which are based the
various axioms and constant terms of the symptom equation–the symptom-code.
In the next chapter, the structural formation of the symptom will be presented.
The symptom formation referred to concerns only emotional-psychological
symptoms that are not governed in the causative stage by organic brain lesions or
any biochemical intervening variables. Further, and as stated earlier, symptoms
that are engraved in the personality to the extent that they become the personality
and not only an aspect of the personality, are not subject to the assumptions and
axioms presented here. Most of the neurotic symptoms of everyday life that char-
acteristically remain only facets of the personality, are solely the subject of this
theoretical organization of the symptom-code, and of the practical application of
this code in the cure of symptoms.
Chapter 3
The Symptom-Code and its Application
In the understanding of this system of assumptions, propositions and axioms

regarding the formation, composition, and dissolution of emotional-psychological
symptoms, there are essentially four phases that encompass the subject matter of
symptom structure comprising the morphology and anatomy of symptoms. The
first phase to be presented is actually a distillation of the exposition of the previous
chapter
Phase 1: Before the Symptom Forms

1. The pleasure principle of life starts it–we want what we want.
2. The chief example of how the pleasure principle works in everyday life concerns
the drive that people have to realize their wishes. The drives are considered
the Freudian classical drives of libido and aggression, and the wish becomes the
chief representative of the pleasure principle. It is the pleasure principle that
contains the drives. When the pleasure principle is gratified we feel empowered.
3. When a wish is thwarted, however, frustration is experienced.
4. The result of a thwarted wish and its subsequent frustration, is a feeling of
helplessness or disempowerment.
5. The natural response to disempowerment is the emotional reaction of anger
which in itself is a pleasurable alleviation of the frustration and disempower-
ment. This anger reflex is natural because when someone is disempowered,
anger frequently becomes the only way to feel reempowered.
6. The need to repress the anger is based on social and psychological injunctions
against aggression.
Phase 2: Formation of the Symptom

When anger is repressed, as in the event of a thwarted wish, and the inability, inca-
pacity, or inaccessibility of expressing the anger directly exists, one must then, in
order to further appreciate this process, remember anger’s basic personality.
19
20 3. The Symptom-Code and its Application
That is, all anger wants to do, is attack. That is its basic nature. Therefore, when
the anger is repressed, it can do nothing else but attack the self, the subject. It can
do nothing else. The anger when repressed therefore, takes the self, attaches to the
self, attacks the self.
This process of the target object morphing into the target-subject invokes another
principle of emotion. Now to the proposition that each basic emotion has a unidi-
mensional personality (anger, attacks; fear, flees), this must be added: In order to be
fully realized as an emotion, to be fully crystallized as an emotion, the emotion must
be targeted toward or attach itself to a person-the object. When the emotion cannot
be directed to, or cannot “take” the object, then the emotion will just hang there, in
a virtual state as it were, a condition that cannot be sustained because the emotion
will not be fully realized without it attaching itself to a person-the subject becomes
the object of the emotion. And here is the important moment. When the self, the
subject, is attacked by the repressed anger, then this moment constitutes the instant
of conception leading to the birth of the subsequent symptom.
Thus, the first step in understanding the genesis of symptom formation – and
the organization of the symptom equation formulated in this volume – concerns the
awareness that, on the face of it, the thwarted wish essentially deprives the pleasure
principle of its reward. The second step emerges from the sense of disempowerment
regarding this thwarted wish. The third step focuses on the reflex of anger as a
response to the state of disempowerment in order to gain reempowerment. The fourth
step is concerned with repression. When the anger, for whatever reason, cannot be
directed toward its intended object, a person, a “who,” repression is therefore invoked
and acts on the anger before the anger reaches consciousness. Now the anger is
repressed and unconscious. The fifth step occurs when the anger is repressed,
because accompanying the repression of the anger is the original wish that was
thwarted or denied. In this respect it should be remembered that one of Freud’s sem-
inal observations concerned his discovery that no wish will be denied. Therefore, the
wish must, through repression, accompany the anger into the unconscious. There is
no other way for the wish to be translated into the symptom if it is not, along with the
anger, subject to repression. When the criterion of repression regarding both the
anger and the wish, as material of the unconscious, is satisfied, only then is Freud’s
axiom that no wish will be denied revealed as a truth. Only then, is step 6 achieved;
that is, that the wish is realized albeit neurotically or perversely as the symptom, or
simply that the symptom appears as a symbol of the wish.
The originally denied wish therefore accompanies the anger, pressed as it were,
into the unconscious–repressed together. Another of Freud’s brilliant observa-
tions resonates here. Freud indicated that we love our symptoms, and this obser-
vation now makes sense. We love our symptoms, obviously, because symptoms
are the wishes, fully gratified, though in symbolic form.
Review of the Six Steps of Symptom Formation in Phases 1 and 2
1. A wish is thwarted.
2. The subject is disempowered.
3. The subject becomes reflexively angry as a way of becoming reempowered.
Phase 2: Formation of the Symptom 21
4. If the anger cannot be directed toward its intended target–a person–then repres-
sion of the anger is invoked.
5. The original wish that was thwarted now accompanies the anger into the
unconscious.
6. So long as the anger remains unconscious it stokes the repressive furnace, out
of which emerges the symptom, which is the wish neurotically gratified in this
transformed symbolic state.
A final seventh step involving the lifting of the symptom, to be discussed
below is:
7. When the anger is made conscious, when the identified who–the person toward
whom the anger was originally intended, is revealed–then it is predicted that
the symptom will lift.
In the following section, these steps are formulated as a sequence of axioms.
Regarding Anger and Symptoms:
Where there is repressed anger not only will there be
a symptom, but there must be a symptom.
Corollary: Where there is no repressed anger, not
only will there not be a symptom, but
there cannot be a symptom.
Where there is a symptom, not only will there be
repressed anger, but there must be repressed anger.
Corollary: Where there is no symptom, not only will
there not be repressed anger, but
there there cannot be repressed anger.
Regarding the Wish:
A thwarted wish results in disempowerment feelings.
Disempowerment generates anger.
Anger that cannot be expressed directly, is repressed,
thereby creating the moment of conception of the
symptom.
In the process of repression, the wish–or rather
the symbolization of the wish–joins with the anger in
becoming unconscious.
The anger remains unconscious and acts to fuel the
transformation of the wish into the symptom. Hence,
no wish will be denied.
Phase 3: The All Important Who

Another axiom related to, but not solely relevant to symptom formation, concerns
the issue of emotions and objects. The axiom is:
All emotion must take an object, and the object is always a person.
The object is never a chair or a lamp. In trying to understand the symptom, one
must always look for the person toward whom the anger was originally intended–
the who.
Thus, the reaction of anger is always about a who. No emotion can just hang
there suspended in mid air, as it were. Of course there are times when the other
person, the object, is absent, or for whatever reason cannot be targeted with a direct
expression of anger. Then, the self, the subject, becomes the substitute target of the
anger–an internal target–so that as stated earlier, the object becomes the self. Thus,
the emotion still has a person to attach to–the self. This then, is the process identi-
fied as the anger attacking the self and can be stated as an axiom, as follows:
When anger cannot be directed at the object toward
whom it is intended, then the subject, the self, becomes
the target, and thus the anger is repressed, and attacks
the self.
Phase 4: The Lifting of the Symptom

When the object of the anger, the who, is identified, and the anger toward the who
becomes conscious, then the strength of the symptom is challenged and the symp-
tom may even instantly lift. Thus, Freud’s principle that consciousness is cura-
tive, is validated but only if it is the emotion of anger toward the who that becomes
conscious. Nothing else can cure. Of course, in the course of psychoanalytic treat-
ment, the unconscious must become conscious as the work proceeds. But it is
proposed here that this process cannot cure anything unless it is anger toward the
object, the who, that becomes conscious.
The axiom is:
Consciousness is curative only when what is made
conscious refers to identifying anger toward an
originally pre-repressed specific object–a specific
‘who’–a person.
What emerges here is the ascendancy of anger and not sexuality or libido, as the
salient variable in all symptom formation. Again, it is proposed that when libido is,
in fact, implicated in symptom formation, it is not because of any impasse in the
expression of the libido as it relates to sexuality, or because of a failure of repres-
sion, thereby permitting infantile sexual impulses to escape. Rather, it is here
suggested that the implication of sexuality in symptom formation only exists
Definition of a Symptom: Infrastructure 23
because due to sexual impasses, failures, or frustrations, the subject becomes dis-
empowered and fundamentally angry about it. Then because of the potential
repression of the anger, a symptom will potentially appear. Clearly, in this formu-
lation it is the anger and not the sexual impulse that is at the core of symptom for-
mation.
Any symptom will be challenged more decisively, if after the who is identified
and the anger toward this object, this who, becomes unrepressed, and if then the
subject becomes actively involved in facing some aspect of the original
problem–that is, the circumstance that involved the subject with the object in the
first place (the symptom context)–then that kind of “doing” implementation will,
in all likelihood, raise the probability of more decisively erasing the symptom.
The axiom is:
When the anger toward the who is made conscious,
then the symptom will become challenged or even lift.
To further reinforce and fortify the cure of the symp-
tom, some doing activity, some implementation, needs
to take place involving the original symptom-context
condition that first led to the need for the symptom.
A final coda relates to chronic, resistive, deeply etched, or engraved

symptoms–those that are not merely an aspect of the personality, but swallow the
person whole, and become the personality. These are the symptoms that resist
any psychotherapeutic modality. Other than symptoms based solely on biologi-
cal causes, these are symptoms that have resulted from psychogenic major
implosions of anger–so much so, that a symptom condition is wrenched into a
permanent personality position. In such cases, it is suggested that the implosion
of anger is really an implosion of the highest intensity of disempowerment and
anger. This is basically rage or fury that creates an anger-debris that permeates
the entire psyche. Such inaccessible symptoms usually can only be defeated
when psychotropic medication is used along with psychotherapy.
In the following chapter, collateral issues of the symptom-code that fill out its
context, will be presented. These issues include: the possibility that certain symp-
toms relieve tension while others increase it, and, an exposition of the psychology
of withdrawal, as the arena in which symptoms are nourished, and flourish. Thus,
these first four chapters of Part I of this volume, essentially comprise the contex-
tual theoretical underpinning of the entire symptom-code utilized to penetrate and
cure the symptom.
Definition of a Symptom: Infrastructure

A psychological/emotional symptom is the transformation of a thwarted wish
(experienced as disempowering), into an involuntary symbolic configuration
(a symptom). The symptom is formed by a reflexive anger response (as an
attempt at reempowerment) toward the who – the person who thwarted the wish
in the first place. Instead of being consciously expressed to this who, the anger,
along with its connection to this who, then becomes repressed.
Implication
In this way, the transformed wish into the symptom satisfies Freud’s discovery
that in the psyche no wish will be denied – so that since the symptom is the wish
(albeit in perverse or neurotic form), then indeed, we all love our symptoms
(including those that are unpleasant or even painful), because they are informed in
the unconscious as gratified wishes.
Chapter 4
On Wishes, Symptoms, and Withdrawal
Positive Versus Negative Symptoms

Are there some symptoms that become reinforced, sustained, and even intensified
throughout the duration of the symptom episode, while others simply relieve
tension? For example, the suffering of psychogenic migraines seems to be
sustained, even fortified, throughout the duration of the episode. Such a symptom
could be considered a negative one. On the other hand, an average compulsion, or
perhaps even a severe one, when acted out, actually relieves tension; that is, the
symptom episode (acting out the compulsion) produces a positive result for the
person, a relief of tension.
Hence, we may consider that in view of this difference between the experience
of sustained or intensified pain with respect to one kind of symptom, and the
relief from pain with respect to another, that symptoms generally could be divided
into two categories that we may operationally define as positive or negative. This
labeling is based entirely on the person’s experience of the symptom as painful or
relieving, and not on any objective criteria of good or bad symptoms.
Where in the sequence of events that generated the symptom in the first place
can we find what it is that makes for the difference between symptoms that ame-
liorate tension, versus those that exacerbate it?
The Wish and its Relation to Ameliorating

and Exacerbating Symptoms
The answer to the question about what it is that determines whether a symptom is
positive or ameliorating, or negative or exacerbating, concerns the person’s origi-
nal wish that was ultimately thwarted. If this original thwarted wish was a direct
one–for a positive outcome of the wished-for scenario – then the ensuing symp-
tom would be positive or ameliorating. The symptom would generate relief of
tension. If, on the other hand, the thwarted wish was a negative one–that is, an
indirect one, a wish to avoid something–then the ensuing symptom will be nega-
tive, or an exacerbating one where tension is increased. In either case, direct
25
26 4. On Wishes, Symptoms, and Withdrawal
positive wish and relieving symptom, or indirect wish and painful symptom, the
subject falls in love with the symptom, because, as discussed previously, the
symptom is the wish satisfied, albeit in perverse or neurotic form, regardless of
whether the symptom is relieving or painful.
Thus, the symptom is locked in, in perverse or neurotic form, and with respect to
cure, it matters not whether the symptom is an ameliorative tension reducer, or a
painful and tension exacerbating one. The cohesion of the symptom, its constraint
or tight parameter, is impervious to reason of any kind. Rational or cognitive logical
appeals or any kind of beseeching of the subject, or any kind of inducements–no
matter how attractive–cannot have any curative effect on the symptom. None of
these persuasions, seductions, or paradigmatic assumptions of normalcy, will ever
have the slightest effect on the symptom. Not the slightest! These are reality
oriented appeals and speak an entirely different language from that used by the
symptom. The symptom does not respond to usual, manifest logic. The reason for
such monumental failure on the part of reality-based appeals, approaches, or even
admonitions toward the subject–regarding a relinquishment of the symptom–-
concerns the very nature of the symptom as an entity in a defined realm of the
psyche. The symptom exists in the unconscious. It is condensed, a symbol for a
wish; and more so, for a fully gratified wish (that we love), albeit in a translated,
transformed, neurotic, or perverse configuration. It is proposed that the symptom
can only be communicated with through the code presented here, involving an
approach that aims to uncover the original wish by identifying the who toward
whom the subject’s repressed anger was originally directed.
Thus, the main theme, and the salient point to the present work, is to indicate
that only when the subject becomes conscious of being angry toward this target
person, will the symptom begin to dissolve. This is the only language understood
by the symptom; that is, by the subject’s unconscious. It is the language of
wishes, repression, and the dynamics of the emotional mortar determining
immutable laws of the connection between the subject and the who–the object,
the other person.
It is in this sense that all of these reality-based genuine appeals, sincere
approaches, and even severe admonishments, on the part of others toward the
patient to relinquish the symptom, are all doomed to failure. The patient is almost
always helpless to do anything voluntarily to assuage the symptom, because by def-
inition, the symptom is beyond the patient’s control. The symptom is a product or a
ward of the unconscious, of repression. The symptom only exists because its host,
the subject, when reacting with the symptom, is basically in a state of withdrawal.
The Symptom and the State of Withdrawal

In a non-clinical, non-pathological sense, withdrawal is actually, for all people, a
natural phenomenon of everyday life, essentially a pause. It is a moment of inner
rest. It is a solitary state. It is never authentically interactional, though it may be
transferential.
The Line 27
Withdrawal is transferential insofar as the person in withdrawal can think,

remember, or recall, any subject matter whatsoever that can be brought to mind.
In withdrawal, rumination characterizes the state. Even when there are others
around, when the subject withdraws, only perfunctory attention to others indi-
cates moment to moment responses. There may be social niceties to honor, so that
nodding to the other person as though one is actually attentive, is what is seen, but
the subject is “not there”–was only ostensibly attentive. The subject is actually in
withdrawal, pretending to be listening, but really only tuned to the self, only lis-
tening to the inner dialogue with someone the subject is thinking about. Or the
subject may be listening to the ongoing monologue/dialogue–self to self.
The Line
A useful metaphor that illustrates this notion of withdrawal, is to imagine a line.
The Line divides reality from fantasy; in front of The Line is reality, a “doing,” an
active place. There is no rumination in front of The Line. Rather, it is a place
where one can be appealed to, approached, or even admonished, and usually with
immediate effect, or at least with immediate response. There, in front of The Line
is where logic reigns, and where genuine appeals, sincere requests, or even strong
criticisms can be responded to. All of this is possible to achieve in front of The
Line. All of these reality-based appeals, are in front of The Line data.
Behind The Line is defined as the arena of withdrawal. The fact that all people
slip behind The Line several times each day, simply signifies that such brief with-
drawal moments are rather successful attempts for all people to take a breather, to
relax for a moment, to quickly recalibrate their balance, and then just as quickly to
step out in front of The Line and resume their existence in the reality doing place.
In contrast, being behind The Line, is existing in a non-doing inactive place, of
rumination and fantasy. It is a place to discharge one’s feelings of anger, rage,
fury, vengeance, depression, and miseries, and also one’s conscious wishes, com-
pensatory needs, and self-esteem tensions. Thus, in this fantasy place, behind The
Line, frustrations can be played out, thereby relieving pressure.
A behind The Line withdrawal – especially in small doses – can also be seen as
a condition of refuge, a sanctuary from worldly demands, expectations, and
failures. This experience and place, behind The Line, in withdrawal, is where
symptoms and the constituents of symptoms–the wish, repressed anger, and the
who become fortified from above, from the level of consciousness–albeit in an
arena of conscious or quasi-conscious withdrawal.
To the psychoanalysis of symptom composition–meaning the amalgam of the
wish, repressed anger, and the who–is now added the collateral factors of the dif-
ference between ameliorating and exacerbating symptoms and their causative
underpinnings. Along with this map of the psychoanalysis of symptoms is also
added the notion of The Line (separating the arena of withdrawal – a non-doing
place – from the region of reality – a doing place – and on the one hand, assessing
normal withdrawal as the everyday experience of behind The Line pauses,
28 4. On Wishes, Symptoms, and Withdrawal
compared to pathological withdrawal on the other hand, the ground for the incu-
bation and sustaining of symptoms.
With these introductions, reintroductions, reviews, and summaries of symptom
formation, and the blueprint to decode, unlock, and cure the symptom, a variety
of clinical cases will be presented in Part II of this book. This blueprint, utilizing
the set of axioms presented here, will be applied to these clinical cases and the
systematic curing of symptoms will be demonstrated. All of the factors in the for-
mation and ultimate penetration of the symptom will be focused upon with an aim
of lifting or curing the symptom. These factors will include reference to:
1. The code for symptoms involving wishes, repressed anger, and the who;
2. Ameliorating and exacerbating symptoms;
3. The issue of the “doing” activity with respect to the original wish;
4. The issue of establishing The Line of withdrawal versus reality-doing.
Subsequently, with a lifting of the symptom, the most immediate and derivative
result will show the subject moving from a behind The Line non-doing position,
to a doing position, one that is in front of The Line.
It should be noted that symptoms do not just appear out of the blue. Each
symptom is embedded in an understandable process; that is, a symptom context.
The belief in the unknowability of symptom formation and the thrall of mystery
or mystification with respect to the phenomenon of the appearance of symptoms,
is simply a result of an absence of discovery, insight, and knowledge.
In the following section, Part II of this volume, the clinical application of the
symptom-code will be utilized to demonstrate that the symptom, its formation,
and process, is quite understandable, and not at all mysterious.
Part II
The Clinical Casebook:
Accessible Symptoms
Accessible symptoms are those that:

1. are not deeply engraved psychotic ones that have usurped the personality;
2. are not chronic;
3. are not chronically entrenched somatized ones;
4. are not derivative of an organic brain syndrome or genetic anomaly;
5. are not an example of a catastrophic rage implosion as a result of a condition of
profound helplessness.
6. remain as an alien part to the psyche and so have not usurped the personality.
Chapter 5
Bottles Under the Bed:
A Case of Compulsion
A young boy, an only child of 11, reported “funny feelings” in his stomach, which
he learned to “cure” (as he said), “by putting bottles under the bed.” The case
began with a phone call from his father, a psychiatrist, who stated that recently
and quite accidentally, he noticed his son was placing “bottles under the bed.”
The father said that he had consulted two other colleagues–a psychiatrist and a
psychologist-the first of whom said medication was the treatment of choice
because the symptom seemed too dense, while the psychologist suggested psy-
chotherapy twice a week. The father had consulted with these colleagues only
after he discussed the “bottles” symptom with his son. He also admitted to being
embarrassed at not knowing how to approach this problem, especially since he
was an experienced professional.
Apparently, his son told him that he began feeling funny in his stomach and
quite naturally knew to put bottles under the bed. The boy reported that immedi-
ately upon placing the bottles under the bed, the funny feelings disappeared, as he
kind of knew they would, and that then he instantly felt better, relieved.
The father, upon further questioning, ascertained that these feelings began
several months earlier, and gradually increased in frequency. It was clear that the
boy’s funny feelings in his stomach and his method of curing these feelings, defi-
nitely qualified as a bona fide clinical psychological symptom. The father further
indicated that neither he nor either of the consultants was able to determine or
identify a cause for this symptom, and all were actually baffled about what
seemed like something quite “strange and even weird.”
The Initial Consultation

He was prompt. He was quite verbal and highly intelligent – an above average
11 year old. Play therapy did not at all seem appropriate here since he was eager
to talk about the funny feelings as well as the bottles. Without even a single ques-
tion posed to him, he volunteered that he knew his father had told me about his
symptom and that he wanted to assure me that he was looking forward to getting
rid of it – especially the funny feelings in his stomach – as well as looking
31
32 5. Bottles Under the Bed: A Case of Compulsion
forward to figuring out what it was all about, what it meant. He made it clear that
he knew it meant something.
He started by saying, “I know it’s completely connected.” He explained that when-
ever he got a funny feeling in his stomach he would also immediately get a corre-
sponding urge to put bottles under the bed. He confirmed what his father had initially
reported–that as soon as the bottles were under the bed, he would get relief from the
funny feelings. In response to my inquiry he also said that the feelings were not
painful; that is, the funny feelings in his stomach were not painful feelings, they were
just uncomfortable, “Like worried feelings,” he volunteered, “butterflies”.
Thus, in the first few minutes of the session, I confirmed that he was indeed
suffering from a compulsive symptom eruption in the ostensible absence of any
obsessive preceder. What seemed to be happening to him was that he had some
generalized somatized condition that he was able to cure through a compulsive,
highly symbolic act, so that in its realized ritual, he got relief by temporarily dis-
solving the symptom–“It was like magic,” he said.
In this sense of the patient’s description of the symptom, the symptom itself
could be considered to be an aspect of a process rather than an isolated event.
First, the funny feelings were preceded by some still undetermined stimulus, and
second, there was the compulsion to dissolve the funny feelings by putting bottles
under the bed. In addition, according to this boy, the cure worked every time. One
of the poignant moments occurred when he spontaneously said, “It’s starting to
happen more and more now, and I’m worried about it more.”
Applying the Symptom-Code

The three major constituents of the symptom code presented in Part I of this
volume, include: 1. a thwarted wish; 2. repressed anger regarding the subject’s
inability or powerlessness to reverse the thwarted wish; 3. Identifying the who,
the person toward whom the anger was originally intended.
The prediction is that if we are able to unravel all three, by definition, repres-
sion will lift and the symbol of the symptom will reveal itself, and the symptom
will then become reconstituted into the original wish, made conscious.
Therefore, in the face of this conundrum of a boy placing bottles under the bed
to relieve funny feelings in his stomach, and based upon the symptom-code, the
question is: What do we already know even before we begin our direct therapeu-
tic process or direct inquiry with him? We know:
1. He had a wish he couldn’t realize; that is, each symptom begins with a thwarted
wish. Our question is, what was that wish?
2. He was angry. Who was the someone with whom he was angry? This question
is based on two principles – the first is: Where there is a symptom there must
be repressed anger; and, second, all emotion, including anger, takes an object,
a person;
3. Hence he is angry at one particular person, and again, who is that who?
Applying the Symptom-Code 33
When faced with any symptom, therefore, applying this understanding, will
transform the most complicated, seemingly baffling symptom into a form that
can be immediately understood, and of course, managed. The symptom-code
presented here permits an approach to this or any such symptom so that an efficient
penetration of the very infrastructure of the symptom can be made–to its very core.
In this case, an entry point in the treatment and decoding of his symptom could
begin almost anywhere within the terms of the symptom-code: seeking the who;
seeking the pivotal original event (the symptom context) containing the who; or,
trying to make conscious the anger itself. In addition, each element of the symp-
tom story, of course, is subject to scrutiny. What kind of bottles are they? What do
they contain? Whose bed do the bottles go under? Basically, no assumptions can
be made about such questions until detailed information is provided by the patient.
Ultimately, it is important for the patient to know that he did have a wish, and
to know what that wish was. Furthermore, it is important for the symbol, that is,
the symptom, to be understood. The subject needs to see that “bottles under the
bed” means something, and to know what that something is. That is, that “bottles
under the bed” relates to a specific feeling (anger), about a specific person (the
‘who’), regarding something that was blocked or thwarted (a wish).
I decided to begin by asking him when the symptom began, when he first
noticed it. He said that it was several months earlier when he started feeling the
funny feeling in his stomach and that then he began putting bottles under the bed.
As soon as he put the bottles under the bed, then like magic, the funny feeling dis-
appeared. He added that at first the funny feeling came only occasionally, but that
now it was more frequent–“all the time, in fact”–and he was, for the first time,
worried that he would not be able to control it and that it would “just keep getting
worse and worse.”
He claimed, “it just happened”; that is, he was saying the symptom just
appeared and that by implication there was no pivotal event that started it, at least
that he was aware of. In contrast, I was tenacious in pursuing an actual pivotal
event, which he assumed he never had, but which I assumed we simply had not yet
identified. After working for a while on trying to pin down some event occurring
prior to the onset of the symptom, he casually mentioned that some time ago (he
thought it was before he had his first funny stomach feeling) he remembered that
his parents had a “humongous fight, a tremendous argument.” He had never before
heard them fight like that. He said: “They were both red in the face and they were
shouting to each other about divorce.” What seemed to scare him was that his
father’s threat to divorce his mother bothered him, while his mother’s threat was,
“only a counter to it,” and he further said: “I think it was made in self-defense.”
I immediately considered this boy’s recollection of his parents’ fight to qualify
as a possible pivotal stimulus that may have originally triggered his symptom and
constituted the symptom context. At that point, I shifted to a focus on the who.
It is clear that an 11 year old boy’s repertoire of objects (important people in his
life), is probably rather limited: parents, siblings, a friend or two, a teacher,
another relative. In this case, he had no siblings, and further, in describing his
friendships, relationships, relatives, and teachers, it seemed unlikely that any of
them would qualify as the who. His mother and father remained as the possible
culprits. Yet, only one, either mother or father, would ultimately be the one who.
Emotion takes an object–singular!
Thus, fundamentally, he would have been angry at one of them. Based on the
sobering effect his father’s declaration of divorce had on him, my theory was that
the who was his father. To further validate this hypothesis and not assuming
I knew which bed he put the bottles under, I then asked him which bed it was.
He answered as though his answer would have been obvious, as though to say,
“of course.” He said, “My parents’ bed.”
And now the puzzle was beginning to coalesce, even in the absence of the pre-
viously recommended twice per week sessions or the use of medication. So far,
we only needed knowledge of the symptom-code. And now it was increasingly
evident that the symptom itself would be under pressure; that is, he and I were
beginning a partnership that would likely also begin to undermine the symptom
by diluting his very own resistance to knowing something important that he was
concealing–repressing, especially from himself. This self-same resistance, like
all resistance, designed to support repression, would begin to lift in the face of
making the unconscious, conscious; that is, in making conscious the anger toward
the who. In this case, his resistance was, of course, supporting repression of the
anger toward the who – that person who, in his unconscious, he held responsible
for the thwarting of his original wish.
Then I finally addressed the issue of what might be considered oedipal
geographic archaeology. “Where under your parent’s bed do you place the
bottles?” I asked. “Is it always in one place, or are the bottles placed anywhere at
all?” Since an emotion, like anger, takes a single object, I was sure he didn’t place
the bottles in the middle, under the bed. It would have to be either on his mother’s
or his father’s side of the bed.
“Under my father’s side,” he immediately answered. “Always,” I asked? “Yes,
always. Only on my father’s side.”
With this answer it became clear that his father was definitely the who. Now,
I wanted to know more about the bottles. I had not assumed I knew anything
about them. I asked him about them, asked whether size mattered as in whether
they were big or small, or the type of bottle. To this, he said, “They all have to be
medicine bottles or about medicine. Some are big and some are smaller.”
That answer was the last piece of the puzzle revealing the entire picture. The
symptom and the whole process of the symptom formation of “bottles under the
bed,” became clear. We would now be able to reconstitute the original wish and
make it clear and conscious to him.
Understanding the Symptom

He was an only child and he needed his family to remain in tact. His focus was to
get his father to love his mother, a positive, direct wish. Thus, the positive wish
produced a symptom process that was relieving; that is, a compulsive symptom
Understanding the Symptom 35
ultimately relieved tension. The symptom, beginning with some stimulus that
produced a funny feeling in his stomach ended in the automatic, compulsive act of
putting bottles under the bed and thereby immediately relieving the funny feeling.
When divorce was threatened, especially passionately threatened, he then felt
his world was about to be shattered. He became frightened and it was this fear,
this apprehension, that occupied his consciousness. However, the salient factor
was not the fear; rather, what was crucial was his anger toward the who, his father.
The main point here is that in contrast to his conscious fear, his anger was uncon-
scious. He could not bring himself to know he was angry at his father. He loved
his father. Apparently, the conflict between the love and the anger was too great.
Therefore, he had not been aware of his unconscious anger and the devastating
emotional and psychological effect it was having on him. It was his anger that
needed attention. Trying to cure his symptom by focusing on his fear could never
cure the symptom. It’s never about the fear!
He believed his mother loved his father but that his father probably didn’t love
his mother. It became clear that he had formed this opinion because his mother was
more demonstrative with her affection than was his father, whom he described
as “more quiet.” And therefore, the fact that he believed it was his father who was
threatening the integrity of his world–actually threatening his wish of keeping the
family in tact–kept feeding this boy’s anger because he felt disempowered in the
face of his anticipated crumbling world.
Furthermore, that the bottles under the bed were always medicine bottles made
this symbol quite easy to understand. Medicine is used to cure. Thus, he placed
these medicine bottles under his father’s side of the bed, obviously because it was
his father who needed to be cured of not loving his mother. Then, of course, when
cured, his father would love his mother. Hence, no divorce, and his wish for the
family to remain whole, would be realized. His world would then be undisturbed,
his security protected. Then, and only then would the unconscious anger disappear
because he would have no identifiable tangible reason to be angry. To the contrary,
he would now, with his wish met, feel quite empowered. With empowerment, there
is no anger, and therefore, no symptom.
Thus, whenever he placed these “medicine” bottles under the bed on his
father’s side all his funny stomach feelings disappeared. This, rather ingenious
boy, who was curing his father over and over again, also satisfied the definition of
a Freudian repetition-compulsion which relieves the immediate tension but never
solves the problem. In this boy’s case, the problem concerned the complex issue
of the wish for an intact family interacting with his anger toward his father, as
well as a repetitive compulsive attempt on his part to cure his father, and in so
doing, also continuing, of course, to cure himself.
Thus, this repetitive compulsive ritual of putting bottles under the bed could
never solve the actual problem. All it could do was symbolically cure his father,
and then again, the logic of the medicine bottles was itself entirely symbolic. This
was so, because the bottles didn’t actually need to contain medicine. Actually,
most of them were empty, or nearly empty. The whole ritual was symbolic. In its
symbolic nuance, in the behind The Line fantasy, imaginary medicinal fumes,
medicinal vapors really, would waft up from under the bed, through the mattress,
and into his father’s corpus–thereby curing his father. Thus, putting bottles under
the bed gave him a good feeling, dissolved the funny feeling in his stomach, and
produced a relief of tension.
Each step of the unraveling of this fully developed symptom was shared with
the patient, all within the first session. He was an astute boy and eager to know
what the symptom was all about. Our work reached the point where he under-
stood that he was angry at his father, and why he was angry. He now knew that
because of his father’s outburst during his parents’ fight, he himself was feeling
weak (disempowered) and this was devastating him because it thwarted his wish
to keep the family intact. That he was trying to cure his father with fantasy medi-
cine, astounded him. He was now also amazed at the logic of his symptom, and
the whole symptom process.
His understanding included: an awareness of his wish, and his frustration about
it; his unconscious anger; and the identification of the who, his father–the object
about whom he was angry. He actually said that knowing it all “was amazing,”
indicating also that it was far more interesting to him than even the original,
seemingly unfathomable mystery of the symptom itself.
At the end of the session he acceded to my request that we have one session
with his parents. When later we convened that session, his parents remembered
their fight but assured him that the fight was unimportant and that they never
intended to divorce or anything like that. In fact, they intended to be together
always. His father verbalized his love both for his wife and for him, and both
parents were entirely believable in their claims of loyalty, fidelity, and love.
This family session further satisfied one of the criteria for the permanent disso-
lution of a symptom; that is, that doing something in front of The Line that directly
relates to the original thwarted wish will more decisively erase the symptom. Even
several years later, this boy’s symptom had entirely lost its power and had never
reappeared.
The question of why this boy reacted so strongly to the event of his parents’
fight, and any other more deeply etched conflicts, could be reserved for further
therapeutic work.
Chapter 6
Holes: A Case of Body Delusion
An elderly man of 80 was committed to a city hospital facility for observation.

He presented with “bizarre behavior,” and a variety of symptoms including depres-
sion, and body delusion. He was quite erudite, and was a published poet. As his
day-job, he had been gainfully employed in the needle trades while continuing to
publish his poems in various periodicals. At the time of the recent onset of his
symptoms he was still at the same job he had held for decades. All in all, the patient
was a robust octogenarian whose full complement of symptoms included depres-
sion, impotence, body delusion, and complaints of a continuously queasy stomach.
His depression became evident when be could no longer get to work on time,
and began complaining of his great problem – that of getting out of bed in the
morning. He conveyed the idea that he also began feeling dispirited and demoral-
ized. He said he had wanted to cry but couldn’t. His impotence was of concern to
him because he said he was neglecting his current common-law wife. His wife
had died some years before. He claimed to have had an uninterrupted active sex-
ual life all of his life until “this tragedy” befell him.
Furthermore, the notation in the hospital chart of “bizarre symptom” referred
to his body delusion. Apparently, this man felt there were holes all over his
body–holes you could see through. The queasy stomach was also unexplained,
except for his pronouncement that “it was all the time,” meaning it never abated.
In disgust, he said, “It’s no good any more–nothing is good.”

The patient was a nice looking man. He was obviously intelligent and appreciated
the opportunity to have the interview. He said he felt depressed, but his acute interest
in our meeting did not indicate that he was in any way chronically depressed.
He seemed to be interested in many things, while his current feeling of hopelessness
was just that: current and acute, and did not seem at all chronic or entrenched.
The first two issues he reported concerned his depression and his body delusion
of holes. Contrary to how he was behaving, he explained that he was not interested
in anything anymore, and that nothing mattered anyway because his body was full
37
38 6. Holes: A Case of Body Delusion
of holes. “These holes that you can even see through them,” is how he put it.
I asked him if the holes were all over his body or if they were located only in one
spot. My interest in asking this question had less to do with any particular aim and
more with creating an ongoing discussion. He said the holes were all over his body
and that he knew it meant he was “through.” By “through,” he explained that it
meant his life no longer mattered and that he was now a useless person.
He reported that his wife had “departed” (died) several years earlier and that for the
past few years he had “taken up” with a very nice lady. He also un-self-consciously
reported that he had been sexually active all of his life but that now he could no longer
function “in the same way.” He also confirmed that he was continuously employed in
the same job for all of his working life. In total, he confirmed everything on his intake
chart, and further, filled it in with greater detail. He also spoke at length about his first
love, poetry, and indicated that he was a published writer.
With respect to his family, he had two sons–one a “very successful lawyer,” and
the other, a struggling actor who frequently needed to be subsidized. He claimed
to be close to both sons and was in constant touch with them. He followed this
discussion by wondering what had happened to him. He didn’t know why he sud-
denly became depressed nor what had happened for him to become so plagued
“with all this craziness.”
When referring to the “terrible feeling” in his stomach, the patient pointed fur-
ther down, toward his genitals, and did this, what might be considered a displace-
ment downwards, whenever he again, referred to his stomach. He sighed deeply
and said, “Look what happened to me.”

As in the previous chapter, what was needed here was information regarding the
three salient components of the symptom code – information about: (1) the
thwarted wish; (2) repressed anger regarding the subject’s inability or powerless-
ness to reverse the thwarted wish; (3) identifying the who, the person toward
whom the anger was originally intended.
Again, the prediction was that if we would be able to identify all three, as well as
help the patient become aware and conscious of them, then by definition, repression
would lift and the symbol of the symptom would reveal itself (the symptom would
then become reconstituted into the original wish made conscious).
Therefore, in the face of this conundrum of an elderly, impotent, depressed
man, with a continuously queasy stomach, and a delusion about holes all over his
body that could be seen through, and based upon the symptom-code, the question
became: What did we already know even before we began our direct therapeutic
process or direct inquiry with him? We knew:
1. He had a wish he couldn’t realize; that is, each symptom begins with a thwarted
wish: What was that wish?
2. He was angry: Who was the someone with whom he was angry? This
question is based on two principles. First, where there is a symptom there
must be repressed anger, and second, all emotion including anger, takes an
object, a person.
3. Hence, he was angry at one particular person, and again, who was that who?
Who is the person with whom he was angry?
When faced with any symptom therefore, applying this code, this understand-
ing, will reduce the most complicated, seemingly baffling symptom, into a pro-
portion that can be immediately understood, and of course, managed. The
symptom-code presented here, permits an approach to this or any such psycho-
logical symptom, so that an efficient penetration of the very infrastructure of the
symptom can be made.
Ultimately, in this patient’s case, a major clue to his symptomatology, perhaps
because he was a poet, proved to be a play on words. In addition, it was clear that
his symptoms did not materialize out of the clear blue sky. Someone got into his
guts and caused him to have that queasy stomach and all the other symptoms that
had him in its grip. He was dispirited and demoralized.
We carefully spent the remainder of the interview going over, step by step, his
activities at the time immediately before he wakened one morning with his depres-
sion. Thus, my decision in this case was to at once seek a pivotal event. He then
reviewed his work relationships and his relationship with his common-law wife.
None of these seemed to yield any sort of event containing the person nor the
crisis; that is, until he began discussing his sons.
The patient finally revealed that he was not feeling good about his lawyer son.
Apparently, what had occurred during this pivotal event, left the patient in a terri-
ble emotional state. He had called this son to ask for a loan because he needed to
help the other son with rent payments. Such requests had also occurred in the past
and were always responded to favorably by this lawyer son. This time, however,
our patient was summarily dismissed and his son, without even ending the con-
versation with a familial “goodbye,” simply put down the receiver–hung up.
We discussed this for a few minutes. It seemed to me that the patient perhaps
had called at an inopportune time and his son, without realizing the effect of treat-
ing the call the way he did–that is, allegedly abruptly, and in the absence of any
consideration or even respect–created in his father a terrible feeling of rejection,
even humiliation. As it turned out, the patient’s sense of humiliation became the
sine que non of this interaction and of its effects.
It seemed obvious that the who had now been identified. Additionally, it seemed
also obvious that he was angry at his attorney son and that it was precisely this
anger that he avoided acknowledging–at all costs. He simply didn’t want to know
about it. He could feel humiliated and subsequently depressed about this humilia-
tion, but would not allow himself to understand, to be conscious of, his deep anger
toward this son. Apparently, he did not want to consciously institutionalize the
breach with his son that was already fulminating, albeit unconsciously.
No, it was not his sexual repression that caused these symptoms. There may not
even have been a sexual repression. What was, however, in all likelihood the
problem, was that the swallowing of his anger, the repression of his anger, anaes-
thetized his sexuality, his libido, so that he could no longer feel sexually
interested. It was the anger that was the emotional culprit, the repressed anger
toward the who-the attorney son. The principle may be stated as: Where there is
anger, there is no libido.
Now each element of the symptom-code had fallen into place. His wish was for
his son to respect him and even show respect with indulgence, and in addition, to
offer the loan without any ambivalence or hesitation whatsoever. This was the
wish that was probably thwarted. Faced with this situation, he then probably felt
helpless, and immediately disempowered.
It can be predicted that to the disempowerment, he felt angry. As stated earlier,
the psychology of such a connection between a feeling of disempowerment and
the emotion of anger is really quite logical. When one is disempowered, there are
times when the only way to become reempowered is by becoming angry. This
particular understanding of the connection of empowerment and anger also
reveals that the emotion of anger is an empowering emotion–a conclusion that is
usually not understood because of the tendency to see anger as negative reaction.
Thus, the wish this patient had for his son to cooperate, was dashed. He became
angry, but repressed the anger because: (1) he was humiliated by the manner of
the rejection; and, (2) because to know he was angry would have been a humilia-
tion on top of a humiliation. His lawyer son was the who, that was for sure.
After discussing his feelings of this son’s rejection of him, he then readily
admitted to seeing the connection between what his son did and his own subse-
quent depressed feeling. Yet, although he saw this connection, nevertheless, he
still was not in touch with his actual anger toward his son. He agreed that
he was disappointed in his son, and he agreed also that he was feeling awkward
about again calling his son. But he couldn’t quite face his anger, or even rage,
toward this son. It was only gradually that he began to notice that whenever he
replayed the event of his rejection by his son, he got “that terrible feeling.”
I assured him that at the bottom of this terrible feeling he was not only dissatis-
fied and disappointed in this son, but that he was justifiably angry at him
because, as I put it: “You felt he was rude, that he was disrespectful, and you
were probably dissatisfied–don’t you think?”
The idea that his son may have been rude and disrespectful, and as a result, the
patient may have been dissatisfied in response to this rejection, very much helped
him to get a bit more in touch with his anger at his son. The rationale here was
that one can have anger at rudeness but not as easily feel angry at being rejected.
Feeling rejected is worse with respect to one’s ego, to one’s self-respect, than
feeling angry. Being angry at rudeness, is more socially acceptable and does not
as easily implicate one’s ego with regard to feeling humiliated. It’s really a matter
of easing into it.
“Okay,” he said. “Yes, he was rude and he should never be rude because I raised
him to be a good boy. So, yes, I am mad at him because maybe now he thinks
because he’s a big lawyer he doesn’t have to be nice to the smaller people.” After a
pause, he said, “Well, no, maybe it’s not that. Maybe it’s just that he doesn’t need
me anymore–like a son needs a father. Like maybe he’s the father, and I’m the son
now. No good, no good.”

The patient needed his younger struggling son not be struggling. Thus, his funda-
mental, primary wish did not concern the successful older son. In this sense, even
though it seems that his wish was for the successful son to provide the necessary
funds, nevertheless, this was not his primary wish. His primary wish was directed
to the younger son who needed the subsidy. The patient needed to provide this
son with the subsidy so that the tension of “where his next dollar was coming
from, could be less.” Thus, this father’s wish was an indirect one; that is, he
wished that his younger son could avoid poverty. The wish was directed toward a
goal defined as avoiding something. Because of this kind of avoidant or indirect
wish, the symptoms the father developed were troublesome, painful, and surely
did not relieve tension. In contrast, had the wish been focused or cast in a positive
direct way, then the symptom, whatever it would have turned out to be, would
have relieved tension rather than sustained it.
In this patient’s case, his repressed anger regarding the humiliation he felt, both
because he was insulted by his son’s dismissiveness and because he was now
unable to help his needy younger son, seemed likely to be related to the symptom
of his impotence. In addition, apparently he had swallowed so much anger that he
also became depressed. The repressed anger, of course, true to its nature, attacked
the self. The symptom of impotence also could be seen as a side effect of the
depression because, as previously stated, his repression of anger, in all likelihood,
anesthetized all libidinal inclinations and sensations. Since the psychological
principle governing such impotence suggests a high negative correlation between
anger and libido, then apparently, anger and libido do not coexist, especially
within normal parameters.
The third symptom of an unrelenting queasy stomach seemed also related to
this libido problem and to his impotence. The clue to this connection of a queasy
stomach and impotence, was his pointing to his genital area whenever he men-
tioned the stomach symptom. In psychoanalytic terms, this kind of slip-of-the-
gesture refers to a displacement of focus. In the case of this patient, his pointing
to his genitals when he was referring to his stomach is considered a displacement
from his genitals to his stomach, or the other way around–downwards or upwards,
as the case may be–meaning, that something is not right down there (genitals),
and is instead, feeling bad, up here (stomach).
Finally, perhaps the most interesting, even fascinating symptom of all,
concerns his body delusion regarding “holes” one could see through that he
believed existed throughout his body. It is the particular meaning of holes that
requires a new synthesis, without which, it becomes virtually impossible to
understand the delusion.
The main point concerns the ubiquitous wish we all have to be adequate, to be
empowered, in essence, to be whole. And this is what was meant by the afore-
mentioned “play on words.” In this case, “hole,” also meant “whole.” When the
patient felt inadequate, after being humiliated, the feeling of needing to be whole
turned into a feeling that there were holes in his body. The delusion of holes in his
body was simply his way of expressing his inadequacy, defeat, shame, unwhole-
ness, embarrassment, and so forth. So long as this condition of inadequacy would
be sustained, would in turn constitute the corresponding length of time that he
would believe in his “holes.” And this condition of inadequacy refers to the reten-
tion of repressed anger regarding a who.
The point at which his anger toward the who, his attorney-son, became con-
scious, was also the point at which his entire symptom-syndrome experienced its
first death knell. That is to say, that in the first place, his entire symptom syn-
drome was a behind The Line drama. So long as this drama with its repressed
anger and the identity of the who remained repressed, he remained in withdrawal,
behind The Line. When he became conscious of his anger toward his attorney-
son, however, he then stepped out in front of The Line, out of withdrawal, and into
a reality doing place. In this new condition, in front of The Line, his symptoms
could not survive.
In this case, the example of the entire syndrome of depression, impotence,
queasy stomach, and body delusion of holes, demonstrated the powerful effect of
symbolism. This patient’s entire syndrome was all symbolic, and had him in the
grip of what was called “bizarre” symptomatology.
When the picture began to clear up for him, he was astounded at how he had
sacrificed himself in order to avoid knowing how angry he was–and even that he
was, in fact, angry in the first place. Even though he said he felt “a little renewed,”
nevertheless, I asked him to do something that related to the original problem.
This was the final step in more decisively defeating the symptom. I requested a
joint meeting with his attorney-son. After much resistance and a corresponding
amount of my persistence, he agreed.
The point that most astonished him was the word play of “hole” and “whole.”
I appealed to him to trust the interpretation by reminding him that he was a poet
and that such word plays probably would be more germane to him than they
would be to an average layperson, that he would be more likely to unconsciously
engage in such word plays than others who were not as connected as he was with
words. He liked that explanation, and it won him over to the interpretation.
His son did attend the joint session and explained that he had not even realized
that the conversation went the way that his father had experienced it. He further
explained that he was in a meeting and couldn’t talk, fully intending to return the
call. As it happened, events kept the return call on a back burner. The patient was
relieved at his son’s apparently authentic and sincere explanation. The son, on the
other hand, was horrified at not being informed, at his father’s request, about his
father’s hospitalization.
The end result was that, through the father’s good offices, the son gladly
offered the subsidy to his brother. Soon thereafter, the patient was released from
the hospital. His entire hospitalization lasted three weeks. He was symptom-free.
The family session was important because it satisfied one of the criteria for the
permanent dissolution of the problem; that is, that doing something in front of
The Line that directly relates to the original thwarted wish, will more decisively
erase the symptom.
Chapter 7
Symptoms Based Upon
Feelings of Rejection:
Strangling, Sweats, and Death
In the following three cases, each patient experienced feelings of rejection, and
developed symptoms directly related to such feelings. In the first case, the patient
developed intrusive fantasies of strangling his girl friend. In the second case, the
patient developed night sweats, so that his bedding and pajamas needed to be
changed because they were soaking wet. In the third case, the patient developed
mortality fears and could not prevent herself from obsessively focusing on the
eventual prospect of her own death.
In all three cases, the severity and intensity of the symptom was a clue as to the
respective causative stimulus of each. In each case, it was relatively easy to iden-
tify these ostensible causative stimuli. In this respect, the intrusive strangling
thought, the physiologically intense response of sweating, and the terribly obses-
sive, incessant thought of death, were all related to identifiable pivotal events–the
symptom context–containing other significant people in each patient’s life.
A Case of Intrusive Thoughts of Strangling

A single man in his 50’s, was always finding new women to date and so his social
calendar was always busy. Yet at no time did he ever develop a long-standing rela-
tionship. The duration of any of his relationships was always a function of how
much his date would focus on him. If he could talk about himself at length, he
liked it better and he would be interested in seeing her again. If his date demon-
strated impatience, or insufficient interest in him, then the first date with that
person would be the last.
This man’s early history was such that his primitive sense of the nature of rela-
tionships, was understandable. He was one of two siblings with a father who was
exceedingly impatient. In order for him to talk to his father, he would need to
think through what it was he wanted to say and then blurt it out quickly so as not
to either bore or anger his father. In contrast, his mother was an indulgent woman
who gave him the feeling that he was special.
Although he never really felt comfortable with his father, ironically he grew to
be just like him–impatient, intolerant, impulsive, inattentive to others, insensitive,
43
44 7. Symptoms Based Upon Feelings of Rejection
and uninvolved. His modus operandi was to seek a woman who would indulge
him as his mother had done.
He was a successful businessman with a great deal of energy. His clients appre-
ciated his no-nonsense style. When his impatience in interpersonal affairs was a
detriment to his relationships, in business this impatience translated into an effi-
cient style that gave his clients the feeling that they were in good hands. They got
what they wanted, and in record time. The patient frequently boasted about all the
compliments he got with regard to this, what he called his “problem-solving
style.” He said, “None of this emotional stuff, just solve the problem–get it?”

At the first consultation, this man immediately reported that since the previous
weekend he had been feeling anxious all the time. What had happened is that his
date and he were in her apartment and he suddenly got the thought that he wanted
to strangle her. He reported that he felt “funny” the entire evening. The feeling
continued after dinner, as well as at the theater, reaching its zenith finally in an
emotional and suddenly anxious crescendo that overcame him when they were
ending the evening at her apartment. The anxiety he was feeling seemed to have
been generated by what he said was his impulse to act out a thought of wanting to
strangle her. It was then that he immediately felt anxious, and the anxiety only
subsided when he excused himself and fled.
He indicated that the week preceding this date, he was on a date with a different
woman, and began having a similar feeling, although at that time the anxiety was
just a discomfort. He stated that the whole thing worried him, and he wondered
whether he could ever again be with a woman without having such thoughts.

It appeared that in this case, identifying the three main terms of the symptom-
code with respect to this man’s dynamics, was a relatively simple task: Each of
his dates was the who. It was they toward whom he was angry. He reported in the
first session that in both cases each woman held forth extensively but not at all
about him. “They talked and talked,” is how he put it. Apparently, they made no
room at all for him to refer to himself. From his narcissistic vantage point this
man was in a severe state of feeling deprived of admiration, of feeling deprived of
narcissistic supplies. In other words, he needed these women to talk about him
either exclusively or almost exclusively. Instead they talked about themselves as
well as about other things–everything and anything but him.
It became obvious that he was quite angry with his dates regarding the focus of
these discussions. His wish was that these women would indeed talk to him about
himself, which they didn’t. Since they did everything but focus on him, he
became impatient and intolerant, and in addition, apparently repressed most or
even all of his anger. After his wish to be focused upon was thwarted, and after his
anger became repressed, then the very next thing that occurred was the appear-
ance of his intrusive thought of strangling.
Of course his anxiety about it all, and his stampede out of his date’s apartment,
and according to him, “out of the relationship altogether,” was a clinical indica-
tion that his thought of strangling was really only an expression of his anger–an
alien thought–and not in any way relevant to a bona fide acting out of strangling.

This patient was having a solipsistic-like episode; that is, he was simply narcissis-
tically impatient. His solipsism was not just a function of his belief that only the
self can be known-his self, that is,-but also a function of his desire, his wish, for
others to demonstrate the same belief, namely, that the only information that
could be important was information about him. Thus, these dates were boring him
to death. Yet, the only way for him not to be bored would be to have all the focus
throughout the conversation on him. As noted earlier, bored, is often one of the
many code words for anger.
Assuming repression of his anger, then it would also follow that the anger was,
as is its nature when repressed, directed at the self; thus, a symptom was to be
expected. In this patient’s case, the symptom that appeared, was an urge to stran-
gle his date. Essentially the intrusive thought of strangling represented his wish,
even his fervent wish, and more urgently, his narcissistically fervent wish, for her
to stop talking about herself or whatever else she was talking about, and to begin
talking about him. His problem was not at all that he was in danger of strangling
her. His problem was that he couldn’t get her to talk about him; in other words his
wish for her to talk about him, was thwarted.
Based upon this understanding of his strangling thought, the prediction would
be that as soon as the woman began talking solely about him, all thoughts of
strangling would disappear. Thus, the strangling thought was another way for him
to say, “Stop talking unless you only talk about me.” On his next date with a new
person, there was no sign of the strangling thought because his date was quite
interested in him and really pretty much only talked about him. As a result he was
not bored (angry), and therefore didn’t need to repress any anger, and his wish
was fully realized. Hence, no symptom.
On the face of it, it seems that his wish was direct (he wished for his dates to
talk about him) yet, in actual practice, his wish was really an indirect one. It was
actually a so-called negative wish: He wanted them (he wished them), to stop
talking about other things. In contrast, a wish that would have been proactive and
direct would be simply for them to talk about him and not focus on an indirect
wish. In this sense, his symptom of the strangling thought made him anxious, and
either sustained or sometimes even increased his tension. It was the dread of
rejection that was the nub of it all. Then in a behind The Line drama, he developed
his symptom.
Thus, a direct wish produces a symptom that relieves tension while an indirect
one reflects an indirect route to the primary wish, and will produce a symptom
that sustains or increases tension. The strangling fantasy reflected the indirect
wish–one that represented an indirect route to the primary wish, thus exacerbating
his tension and worrying him.
A Case of Nighttime Sweats

A man in his 30’s suddenly began awakening, to find himself soaked in sweat and
somewhat disoriented. His wife would help him change his pajamas and then she
would change the bedding. He had always been a good sleeper and this symptom
had never before appeared.
He consulted a physician after the third or fourth such sweating episode. All of
his tests were negative, and he was told that these night sweats were probably a
function of some emotional or psychological problem.
He and his wife had been married for a decade. They were a very social couple,
and were also actively involved in their respective large extended families. They
had not seriously contemplated having children and had always “put it on the
back burner.” He was an attorney and his wife was an instructor at a culinary
institute. They were affluent, lived in an elaborate, opulent apartment, and would
spend weekends at their country home.
Their sexual history had been problematic. He was shy, and she was “high
strung.” Thus, the conjugal part of the relationship seemed complicated and by
implication, probably tense, or at least, compromised. In addition, in the recent
past they had begun to bicker, and despite his love for her, the relationship
seemed, in this respect, to be getting worse and not better. This, despite their
avowed promise to one another from the beginning of their relationship, to try to
be nice to, and to accommodate each other. They would occasionally repeat this
vow, especially after some of their bickering episodes.
None of these promises had the strength to withstand the quality in his wife
that he found most difficult, her stubbornness, and the quality in him that she
found most difficult, his excessive compliance. Thus, although he expressed love
for her, he also indicated that he experienced an abject inability to have any sway
with her. He began to feel that his ineffectiveness was becoming more of his typ-
ical part of their relationship, while generally speaking, she was becoming more
of the assertive or dominant one. He claimed she was “an angel otherwise,” even
though he reported that on occasion she also began making jokes about these
night sweats. She would tell him that the night sweats were like bed-wetting or
crying episodes, and then would laugh, and say that these were only jokes, and
that a sense of humor is what was needed.
In contrast, he thought the sweating episodes presaged some terrible disease that
was developing within, notwithstanding the doctor’s clean bill of heath. He also
considered the possibility that he may have had terrible dreams but not remem-
bered them. He was, in his desperation to understand his symptom, grasping at
The Initial Consultation 47
straws. His wife disagreed and tried to persuade him that there was nothing wrong
with him physically, and in addition, said she didn’t think his sweats were a result
of bad dreams.

“I think it all started because I mentioned that maybe we should start thinking
about having a family of our own–meaning having a baby.” This was just about
the last comment he made at the end of the first session. It came to him as an
epiphany as he was beginning to leave. He said, “Hey, that might be it. I think
everything started after that.”
The entire first session was devoted to a description of his night sweats, his
work as an attorney, his relationship with his law firm partners, and also about his
relationship with his wife, whom he claimed he adored, despite their “different
personalities.” His insight at the end of that first session contained the substantive
material out of which, in the second session, emerged the stuff of the symptom.
Yet, in that initial first session, his narrative was characterized by complaints.
He didn’t like one of his partners, and since his was a so-called boutique firm with
only eight lawyers (four of whom were partners), having difficulties with one
partner was a problem.
Further, he said that his wife was beautiful and that he had never stopped being
in love with her even though it was hard for him to get her to do anything he
wanted. They attended the cultural events that she chose, went to various other
events also, he thought, that she was more interested in than he, and vacationed
where she wanted to vacation. He also admitted that he didn’t really care about
these kinds of decisions and usually left things to her.
The profile of their relationship that emerged during the first session was one
in which a rather successful but really passive, submissive, and deferent man,
was married to an assertive and willful woman and that as the years passed, the
tradition that had developed in their relationship consisted, on his part, of an
ineffectiveness, and on her part, on an insistence on having things the way she
wanted them. The onus, however, was on both of them. It seemed the wife was,
according to him, willful, stubborn, unreasonable, and overentitled. Yet he him-
self, was in collusion. He made no real effort at asserting himself generally, or
even specifically, of asserting any particular entitlements that he may have felt.
Thus, the picture of their relationship, in the sense of a metaphor, was one in
which he would probably have had to sweat bullets to get anything he wanted.
Better yet, he probably felt there would be no chance of igniting any real striving
for something he wanted, so the sweating of bullets would then, necessarily,
have had to be done symbolically.
This man’s epiphany at the end of the first session regarding his suggestion of
starting a family, and its relation to the onset of his sweating symptom, as well as
his description in the second session of his relationship to his wife, revealed that
he felt that any further discussion of having a child with her would be met with an
automatic, even tacit dismissal. His desire to discuss this issue with her, espe-
cially since his was of a secondary status in their relationship, meant that he could
not be quite direct enough in impressing her with what he wanted. Moreover, his
apparent trepidation in the relationship also may have meant that he himself prob-
ably wasn’t even sure that he really wanted to have a baby, even though, in fact,
he really may have wanted one. The point is that presumably, and in effect, he
may have felt so diminished in the relationship that to really want something
without his wife’s approval probably could not be brought to consciousness by
him in any vivid or crystallized way. In addition, it seemed that he was operating
with a large measure of denial. For example, no matter how much he complained
about her intractability, he maintained that he loved her nevertheless. His denial
was not so much related to the veracity of his love for her as it was directed to the
avoidance of a self-awareness regarding strong negative feelings toward her that
might be present, coexisting with his love for her.
However, in short order, it became evident to him that he really did want a child.
Apparently, he and his wife had several quick interactions about this subject, all of
them ending with his wife abruptly exiting the discussion. He then broached the
subject with her in a more direct manner, which she rejected out of hand. “I’m not
having a baby, period,” is how he reported she said it. There was no further discus-
sion. She indicated she had never been keen on having children, and that attitude
and feeling had not changed. She wasn’t sure it would ever change. No matter
what he said, the answer was the same. It was then that he felt entirely silenced
and rejected.
It now seemed that the specific stimulus in the formation of the symptom was
this exchange about having/not having a child. This interaction preceded the
appearance of his night sweats, and was most certainly the pivotal event that set
off the psychological-emotional process leading to the manifestation of his night
sweats symptom.

With respect to the symptom-code, it was clear that the who with whom he was
angry, was his wife. The fact that he could not access his anger toward her seems
to support the assumption that anger was indeed present in this man, but that the
anger was repressed.
With respect to the wish, his sense of rejection implied that his wish was for his
wife to change her mind and not reject him; that is, his wish would be considered
an indirect one, a wish for him to avoid something, to avoid rejection. Thus,
because it was such an indirect avoidant wish (to avoid rejection), then it could be
predicted that the symptom would be one that sustained or increased his discom-
fort. The night sweats were terribly inconvenient, uncomfortable, embarrassing,
and all encompassing as well, leaving him somewhat disoriented and in a sleepy
state, ultimately making him feel regressed.
A Case of Obsessive Thoughts of Death 49
In the final analysis, the symptom was the wish gratified, albeit in neurotic or
perverse form, because in order to possibly get what he wanted – a child – he had
to sweat.

As a case in which the subject was rejected, the symptom of night sweats was a
direct link to what this man really wished for. At first, his description of his wife
sounded as though she was an angel. Yet, a more detailed history revealed that
there was much under the surface, and outside of his awareness, suggesting a
more complicated story.
The onset of the symptom was an acute one and there was no history of any
chronic symptom in his personality even remotely resembling this highly idiosyn-
cratic one of night sweats. There was also an absence in his history of any
severely somatized symptoms, and no evidence of any psychotically entrenched
symptom, or of any delusional thinking. Although his symptom of night sweats
was indeed an accessible one, subject to psychotherapy, nevertheless it was one
that sustained his discomfort and his tension, because essentially, his wish was for
his wife to become less intractable and more reasonable so that perhaps he might
be able to then have his wish realized of having a child. In this sense the wish was
for his wife to shift her disavowals regarding having children. Because of this
indirect targeted wish, his symptom of night-sweats caused him embarrassment
and psychological and emotional distress.
With progressive sessions, it became evident that it was not some minor or
even parenthetical urge he had to become a father. In fact, he confessed he had
been wanting a child for a while but had only recently broached the subject with
his wife, and correspondingly, been rebuffed by her. It was this experience of
rejection, along with his belief that he was helpless in the face of her refusals, that
ultimately led to his repression of anger or even rage. Therefore, the extent of his
unconscious anger toward her, seemed to have produced a rather exaggerated
symptom in which, hypothetically, he may have been symbolically matching the
extent of her stubbornness and refusals, by an equal amount of effort in this
highly symbolic act of doing something that would get him his true wish–a baby;
he was sweating for what he wanted.
A Case of Obsessive Thoughts of Death

A woman in her late 60’s had been consistently diagnosed by various clinicians,
over a half century, as a hysteric. She was extremely sensitive to stimuli of various
kinds and had what is psychoanalytically known as a thin stimulus barrier. For
example, she was overly sensitive to any kind of medication, and could feel ill at
the slightest ingestion of any new medicinal agent. Consistent with this hysterical
style, taking medical tests was anathema to her because the anticipation of such
tests could throw her into a panic. Any suggestion of an invasive procedure of any
kind would prove to be extraordinarily aversive to her and she would effectively
neutralize all such attempts with the maximum protest. She would simply refuse
to accede to the doctor’s request for whatever test was called for.
She was, by her own definition, “spiritual,” and would consult with all kinds of
crystal ball gazers, self-appointed gurus, and various and sundry unconventional,
so-called alternative types of self-proclaimed treatment personnel, like-minded
spirits and “specialists.” In addition, and ironically, despite her resistance to conven-
tional medical attention, she was hypochondriacal and so would habitually visit
conventional medical specialists, only to then resist their treatment suggestions.
She was a large woman, quite overweight, and given to passivity; that is, she
would want everyone to do for her, often claiming fatigue and nausea. She was
widowed, but her two adult sons were always trying to accommodate her, and
would provide her with housekeepers, cooks, and even chauffeurs, to drive her
here and there, especially to her doctors’ appointments. No matter how much was
done for her, she would consistently complain, whining that things were terrible.
The only arena in which her passivity was absent, was at her place of business, a
physical therapy practice. She was part owner, and apparently this status had
given her a great sense of empowerment.
Despite her obesity, she was constantly eating sweets, and her diet consisted of
anything she fancied. Finally, in the recent past, immediately before she initiated
psychotherapy treatment, she began having intrusive and terrifyingly obsessive
thoughts about dying. In each and every conversation she would have with family
members or friends, she would steer the conversation to the issue of death.
It was these death thoughts that created terrible anxiety in her and drove her to
seek psychotherapeutic help. The first thing she said in the very first session was:
“Do you have them too?” What she wanted to know was whether the therapist
also had such death thoughts, as though she couldn’t imagine anyone not having
such thoughts. However, in her case, such thoughts were obsessive and she
claimed she thought them many times each day until she felt consumed by them.
“Isn’t it terrible,” she said, wide-eyed. “Doesn’t it bother you that everyone
dies?”

She began with information about her late husband who had died 10 years ear-
lier at the age of 80. He was more than 20 years her senior and apparently had
always been devoted to her. When they married, she was not quite 19, and
he was about 40. He died suddenly of a heart attack one week after they
celebrated their 40th anniversary.
Her husband was the co-owner of a large physical therapy practice. She first met
him when she was17. He had hired her part-time with an official job title of assis-
tant secretary. She was thrilled to have the job and was grateful to him for hiring
her. The job consisted of general office work, some filing, and running errands.
According to the patient, he became friendly with her soon after she began work-
ing there. It didn’t take very long before this friendliness evolved into a mentoring
situation, which developed quite naturally because the patient had lost both parents
in a plane crash about three years earlier, when she was 14. She was then very
much in need of a parent figure, especially since she was quite a dependent person.
After the passing of her parents, she moved in with an older married sister who
was busy raising a family The patient felt lost and proclaimed: “My husband
rescued me.”
After her husband died, she began to experience intermittent bouts of “depres-
sion and fears,” but the support of her two sons seemed to stem the tide of any
psychopathological momentum. Occasionally, over the past 10 years, she would
think of death and would, as she put it, “get a shiver.” But this “shiver” experience
was fleeting. It was only in the recent past, preceding the first consultation, that
she began to obsess about death, and for the first time, she was not able to avoid
the thought. She was now vulnerable to a state of “shiver,” much of the time.
She also stepped into her late husband’s role as co-owner of the business, and
the partner in the business ostensibly welcomed her presence. Naturally, the part-
ner was the clinical professional in the business, and the patient was responsible
for the administrative end. This seemed to work well for some years. Yet, some-
how over the past year, the practice began to dwindle, until their patient census
was so low that the business could no longer justify its existence, and it was
agreed by both of them to finally terminate the partnership and the business. The
partner took the remaining patients into his own physical therapy private practice
agreeing that over a certain period of time, she would share in a portion of the fees
yielded by these patients.
This agreement worked smoothly until she discovered, that unbeknownst to
her, this partner had been siphoning patients throughout the year, and most likely,
over all of the time since her husband’s death. As a result, the partner had devel-
oped a thriving practice elsewhere. She began to experience the obsession with
death almost immediately following this revelation.

It seemed that what kept this large, rather sturdy woman with the fragile ego
intact, was the sense of empowerment she enjoyed from her position as co-owner
of her late husband’s physical therapy practice. It was the only place where she
felt whole. Otherwise, she was complaining, passive, and dependent, and gener-
ally displayed a rather sour disposition.
After her husband’s death, she began to intermittently experience fears of her
own death. It then also became evident that the death of her business, along with
her sense of profound sudden disempowerment regarding what she called “being
fleeced,” as well as her helplessness with respect to gaining some rectification, and
even restitution, rather than producing a flattening of affect and depression, instead
generated an agitated state of obsession with her own demise, her own death as the
thematic centerpiece of this obsession. In addition, it would not be far-fetched to

assume that she really was wishing for the death of her former partner.
Because her symptom was so obviously related to this recent traumatic event of
her disempowerment, the obsessive death fear was highly likely to be an accessi-
ble symptom–one that would yield to psychotherapy through the application of
the symptom-code. For one, her anger toward this former business partner was
palpable, and it was easy to see that he was the who. Two, even though it was
obvious to her that she was furious with him, nevertheless the extent and depth of
her sense of disempowerment, and the profound helplessness accompanying it,
could not help but generate a considerable rage reaction, much of which was
probably repressed. Once the rage was repressed, the symptom of the intrusive
obsessive thought of death became a logical product of her psyche.
So what wish did the death obsession, the symptom, gratify? The answer to this
question lay in the issue of the death of her husband, the death of her business,
and her presumed wish for the death of this partner. However, her basic wish, the
most immediate one, focused on avoiding something. This “something” she
apparently wanted to avoid was the thought that she had been undermined and
rendered helpless. It was a thought that she found so painful that it became impos-
sible for her to specifically focus, no less dwell on it.
Finally, the astounding psychological fact seemed to be that what she really
wished for, was her own death. Symbolically speaking, being dead would mean
she was not compelled to look at, think about, or experience the worst possible
thought, that of complete disempowerment, and therefore, of nothingness, of a
fractured life and a fractured self-esteem. Since the wish was an indirect
(avoidant) one, then the obsessive death symptom produced an increase and not a
relief of tension.

The basic principle underlying the assumption that she wished for her own death,
and that this wish underpinned her obsessive focus on, and extreme fear of death,
lies in the discovery made by Freud. It was a discovery of major significance in
the understanding of the operation of the psyche, its logic, and its products–its
manifestations. Freud said that behind the fear is the wish. In this case, the wish
was to avoid the pain of her dreadful situation – to be dead is to avoid the pain.
Thus, again, according to Freud, no wish will be denied, and so the symptom is
the wish gratified, albeit in neurotic or perverse form.
To continue in this psychoanalytic frame, her husband’s death also qualified as
an event that disempowered her, and for all intents and purposes, generated rage
against him as well, especially because of his unfair treatment of her by his
dying–and, in addition, by dying so suddenly, without preparing her, without
warning her. In the psyche, where logic is influenced as much by the rules of
needs, and by the personality of basic emotions, as much as it is by reason and the
rules of civilization, she, whether rightly or wrongly, almost certainly felt
abandoned by him–death or no death. Her reaction to this abandonment had more

to do with needs and emotions than it did with reason or logic.
In a dependent person, and especially in this woman, who had been so shel-
tered by her husband, this sort of sudden death would, of course, usually be expe-
rienced not only as an abandonment, but more specifically, as an oedipal
abandonment. In fact, such an unexpected sudden death, especially of an oedipal
figure, can be experienced as emotionally equivalent to a homicidal act. And in
this case, so far as she was concerned, the homicidal act could be understood as
having been perpetrated by her husband with her as the victim. In this sense she
must have been furious with him, repressed the anger, and had the first of her
bouts with obsessional death thoughts. What saved her then, when her husband
died, was the structure offered her by the business, and the opportunity to be pro-
ductive in it. Apparently, that’s what stemmed the flow of the potentially chaotic
reaction in her psyche that could have easily prevailed were it not also for the
presence of her husband’s partner, who provided her with a surrogate oedipal
figure, that in all likelihood calmed her raging unconscious.
Her immediate problem was that she was spending far too much time behind
The Line in withdrawal fantasies. With a further integration of the dynamics of
the symptom-code, the fear-of-death symptom would be more accessible to cure.
Chapter 8
Gazing at Corpses:
A Case of Morbid Compulsion
A 29-year-old physician, in order to view corpses that were in various stages of

dissection, began to obsess about visiting the pathology department of the med-
ical school/hospital to which he was affiliated. He would fix on this usually after
working hours, when his shift at the hospital was completed.
The thought of making this sort of “visit,” began rather as an idea. “It came
from nowhere,” he said. Apparently, it felt almost incidental. “At the beginning,
it was only a thought,” he said. Then the idea began to insinuate itself into his
consciousness as an intrusive thought, occupying more than just an incidental
moment in his overall stream of consciousness.
After a while, the intrusive nature of the thought reached the point where the
patient finally diagnosed himself as “being possessed.” Of course, what he meant
was that the intrusive thought felt to him as though it was put into him. About
viewing these corpses, he said, “It was obviously weird – I actually wanted to
look at, or really, gaze at, dead bodies.” Then this “possession” began to cause
him tension. The tension increased with time as he increasingly felt that he actu-
ally needed to see the bodies. He also noticed that whenever he actually viewed
the corpses, his tension abated. Thus, the intrusive thought caused him tension,
but acting on his compulsion enabled him to relieve the tension.
When he first began visiting the pathology department, he felt relieved gazing
at the corpses. However, he knew that his behavior was, as he put it, “sick.” It was
this idea of it being sick, and his realization that he was in the grip of a complete
compulsive symptom, that eventually led him into treatment.
This person had been at this medical school/hospital for the past two years as a
staff physician in cardiology. He reported that, at this time, his wife had noticed
that he was beginning to seem removed, detached. She would ask him what he
was thinking about, and his answer was the standard, “nothing.” It was only after
two or three months that he slipped with the information that he was spending
time after work in the pathology department, at which point his wife wanted to
know what he was doing there. Then he confessed that he was body watching,
looking at corpses. He told her he couldn’t help it and that he knew there was
something wrong but didn’t have the slightest idea what it was that was wrong.
She became alarmed, they discussed it, and he came for treatment.
55
56 8. Gazing at Corpses: A Case of Morbid Compulsion

“I gaze at them.” That was his first reference to looking at the corpses. “And
I don’t know why. It’s a mystery. I know it’s a symptom.” In short order, he
described his life and his work, and based upon his body- watching impulse, diag-
nosed himself as having a morbid compulsion. The diagnosis was accurate.
Further, he said that when he had the thought of wanting to go and view the
corpses, but for whatever reason was unable to, he then felt an increase in tension.
The tension would last, and would be the energy that fueled his inability to stop
thinking about it. The only way for him to feel relieved was to get to the pathol-
ogy department and look at the bodies.
In this first consultation, and in a cursory manner, he focused on his child-
hood. He indicated that, throughout his childhood his family was encouraging
and affectionate with him. He then described the history of his courtship and
marriage, then his medical school experiences as a student, and chronologically
from there, his internship, and finally his residency. He described friendships
and professional relationships, and expressed consternation at not being able to
understand what had happened to him to develop such an obviously disturbed
clinical symptom. He claimed never before to have had any symptoms that could
remotely even be said to be psychological. Yet, he felt this morbid body watch-
ing was entirely psychological.
He said that he and his wife discussed it each night when he returned home
because, after work, before he would leave for home he almost always made a
first stop at the pathology department. His wife had begun to feel that he was
overworked and that the symptom may have represented his feeling that he was
“dying” from fatigue. Hence, his gazing at dead bodies would be an identification
with being dead because of working so hard. According to the patient, his wife
had taken some psychology courses and had a theory about the psychology of
identification, as well as mentoring or modeling behavior, which according to
him, she applied to almost any problem.
The patient dismissed his wife’s theory largely because he did not agree with
her assessment that he was overworked. The truth was, he said, that he felt under-
utilized in his hospital department, so he was not feeling at all overworked. He
also said that at times he would get “a fright” that maybe he had some uncon-
scious impulse toward necrophilia, but then again denied ever feeling erotic
toward the corpses. He said, “I know, at least consciously, that I have no sexual
feelings about the bodies whatsoever. It’s not that. I’m pretty sure it’s not that.”
Finally, before the end of the initial session, he began to discuss his current job
responsibilities. To the question, “In what respect do you feel underutilized?” he
easily answered, “The chief of service just doesn’t use me enough.” This led to a
discussion of his relationship with the chief of service, who, as it turned out, he
was at odds with.
The chief of service had been ambivalent about hiring him in the first place,
but the doctor-applicant the chief of service chose selected another hospital,
so that the chief then settled on the patient as a second choice. Somehow this
information had gotten back to the patient and he began feeling awkward when
in the chief’s presence.
The patient also noticed that this chief of service was assigning duties to other,
less experienced members of his staff, while omitting the patient from some of the
more interesting assignments. A somewhat acrimonious confrontation about this
presumed slight by the chief ensued, and in the end, the chief denied the patient’s
allegation of neglect.
The patient said that the chief “didn’t have the guts to just call a spade a spade.”
The patient felt that it had been since then that “a cold relationship” had devel-
oped between them, and the patient, in addition to feeling underutilized, began
really to feel ignored.
It was not possible to pin down precisely whether the friction between the chief
and the patient correlated to the onset of the patient’s symptom, but it seemed that
such an unpleasant work situation would certainly have involved, or even chal-
lenged, the patient’s identity as a physician, and also very likely raised issues of
competence, and professional respect.

In this case, the symptom had an acute onset in a person who had never before
complained of any kind of psychological disturbance. Hence, there was no
reported history of chronic embeddedness of the symptom in his personality. His
health was excellent and there was no reason to assume that he had developed any
kind of chemical change that would cause a paranoid or morbid compulsion to
specifically gaze at bodies. The fact was that there was nothing he wanted to do
with the bodies but look at them.
In view of this particular onset-pattern, the symptom would have to be consid-
ered an accessible one with respect to psychotherapy, with the prediction of a com-
plete and efficient cure. Of course the questions to answer were: What was his
wish? and who was the who? The assumption was also accepted that he was angry
at this who and finally, that the anger toward that person was repressed.
It soon became evident that he was terribly put off by what he considered a
very transparent ostracism by this chief of service, who now became a chief sus-
pect in the search for the who. His wife was not a good choice for the original
object of his anger because their relationship seemed to be on solid ground, and
he felt that his wife was, and had always been, a great support for him. A review
of the remaining cast of characters in his life was fundamentally benign. It was
both by default as well as by an objective look at the people in his life that the
choice for the who was reduced to one person–the chief of service.
Thus, the stage was set to analyze the symptom by considering the chief of
service as the original object of his anger. The remaining task was to identify his
basic wish. It seemed that the wish would have been some hope, even desperate
hope, that the who, the chief, would resolve his dissatisfaction toward the patient
and treat him as he did all the other professional staff.
58 8. Gazing at Corpses: A Case of Morbid Compulsion

It also seemed that the key to understanding the meaning of the symptom lay in
the patient’s relationship within his nuclear family. For example, in his childhood
he felt entirely legitimate and loved. At the hospital–his professional family–the
chief of service, symbolically also a parent figure, and who could for many, be a
nurturer, someone who encouraged participation, and offered support and reas-
surance, was for the patient, someone to consciously fear and perhaps, even
unconsciously hate. As a child, at home, he indeed achieved his aim of gratifying
his wishes for love and attention. However at the hospital, he was not at all able to
achieve this aim. And since he had little or no experience with rejection, now he
was apparently unable to manage it well.
It was a good bet that the patient was essentially angry with the chief, espe-
cially because he felt he could not be empowered or have any influence whatso-
ever in the department, so long as the chief was in charge. Disempowerment was
the patient’s strongest conscious feeling. If this was the case, then he would have
been instantly furious as a way to reempower himself. However, it seems obvious
that he was not able to express the rage directly. The assumed repression of the
anger, therefore would naturally produce a symptom that in its symbolic form
represented the gratification of the wish; that is, with the chief of service dead,
then at least the patient’s sense of rejection would be nullified.
This interpretation was made in the session and the patient instantly recognized
the truth of it, that he wanted the chief of service dead. He was so angry at this chief
that he acted the anger out by urgently needing to look at dead bodies. He was really
acting out his wish that whenever he went to the pathology department, the body he
would see, would be that of the chief. So he constructed an elaborate and seemingly
bizarre scenario in which he got the chief to be dead symbolically, and so felt much
better when he viewed the corpses.
After examining the meaning of the symptom, the patient felt that something
had changed and that the entire ritual now had a different meaning. Of course,
what he meant was that the whole thing was no longer unconscious. As an uncon-
scious ritual it had one meaning and created a corresponding mysterious mood.
On a conscious level, however, the mysterious mood was absent and the meaning
was different because there was no longer a need to act out something without
knowing what it was. The patient no longer felt possessed. In addition, he was
sure that his morbid compulsion to gaze at dead bodies could no longer have a
grip on him.
After a while his relationship to his chief of service also evolved and the patient
felt no longer either afraid or angry at this person. Apparently, because of a
change in the patient’s attitude to this chief of service, both the patient and the
chief began to react more favorably to one another.
Of course whenever he acted out the body watching, his direct wish for the
chief to be dead relieved his tension. His new attitude toward the chief also moved
him from a behind The Line position into one of “doing,” in front of The Line.
Chapter 9
Sin of the Priest: A Case of Obsession
“It’s a good thing that thinking something and doing something are two different
things. Otherwise you could call my case, ‘The Sin of the Priest.’ But, thank
God,” he continued, “it’s all on the level of fantasy.”
This was the first remark made by a 70-year-old male priest after he introduced
himself at the very first session. He was a portly man with a big stomach and an
affable and easy manner. He was intelligent, erudite, and psychologically minded.
It was strikingly clear that he was not at all shy about relating the events that
encouraged him to seek treatment.
It relieved him to say that he was perhaps close to sinning but had not really
sinned. It was not that any act of his was, according to his own standards, sinful.
Rather, at first, it was not clear whether or not he actually believed his stated certainty
that he had not sinned. In other words, the question was: Did he or didn’t he?

A review of his recent therapy history was how he introduced his intrusive
thought. Apparently, his former therapist was the one to identify his thought as
intrusive. He had seen this therapist for a short period of time in an attempt to rid
himself of this intrusive thought that had become an incessant preoccupation.
But the treatment had not affected the symptom at all, and after a while, he
discontinued his sessions.
The thought involved a woman parishioner who had been a member of his con-
gregation beginning some years earlier. He said, “When I first saw her, I was
instantly smitten.” At that time, he was in his mid-60’s and she, in her 30’s. “Now
she’s probably about 35, and I’m 70,” he continued. His focus on the difference in
their ages was also a factor in his difficulty in thinking about this woman. He indi-
cated that she was beautiful and that he had always been, and was still now,
beguiled by her. He also said that his ideas about her had been torturing him for
years, and that it was these ideas that had intruded into his psyche, into his con-
sciousness, and like a song that can obsessively haunt a person, this intrusive
thought was every bit as relentless.
59
60 9. Sin of the Priest: A Case of Obsession
One of his fantasies regarding this woman was that he would leave the church
and marry her. He claimed she was the only person in his priestly existence who
had ever had this sort of effect on him, and that because of his obsession with her,
and especially because of his intrusive thought, he also felt that his personal
dignity was compromised. Thus, his embarrassment was with himself alone. As it
turned out, the intrusive thought was actually more than a thought, it was a
rhapsody!
Over the years, he and this parishioner had gotten to know one another and
although they had often chatted, and even worked together on a church project,
she had never approached him either for advice or confession or for any other
kind of non-church contact. In addition, he said she had never flirted with him or
otherwise indicated that sort of interest. However, she would unfailingly, always
express appreciation whenever he would reflect back to her what he considered to
be her positive attributes, and he was sure she knew that he admired her. In this
respect he admitted that it was he, who both in oblique ways, and sometimes in a
studied, although tentative manner, was the one who flirted. However, he did it
indirectly, and with hoped-for subtlety, so that it was more like an autistic com-
munication about which, probably, only he would be aware. Thus, he felt he was
involved in a one-sided love affair.
When these so-called autistic trysts occurred, he would think to himself:
“What am I doing? This is insanity.” Yet, he was in an inexorable thrall with
respect to the feeling he had for her. He felt less in her actual grip and more in
his own–where everything about this situation turned in on him. He then also
indicated that about the time the intrusive thought crystallized, he had become
gluttonous, and because of this unusual appetite, gained 40 pounds over the
period of the past several years, equal to the life-span of his intrusive thought
symptom.
He then described the symptom itself by introducing it with what to him
was a terribly dispiriting story. He said that three years earlier, this woman
had married a fellow parishioner. He quickly went on to say that, at present
they had no children. It was possible that he quickly added the information
about her childless marriage because in that way he could possibly keep her
virginal. He also admitted to not being able to bear the thought that she would
be in any conjugal relationship with anyone else. So far as he was concerned,
she was saint like, and entirely, as he said, “unsullied.” He was able, at times,
to make himself believe that her marriage was strictly for companionship and
asexual. He then admitted to feeling that this was nonsense, so that at other
times he would try to imagine what her face looked like in ecstasy, and would
then try to visualize her expression during what he imagined to be her orgasm.
When his thoughts took this turn, he said he felt himself “sink into nothing-
ness,” and he had great difficulty coming out of, what he then considered to
be “a despair.”
He introduced the intrusive thought by saying: “Some time after she married,
I noticed I was having this strange thought.”
The Intrusive Thought

“In the thought, in the fantasy, she tells me that she has scores and scores of cysts
and little sores like pimples, that get popped and extrude pus. They’re all on her
back and they look like little craters; red around the edges with pus accumulating
at the head. She tells me they are painful and that she cannot permit any doctor to
puncture them because the slightest pressure on her back can cause severe pain.
Well, no, not exactly. I think what it is in the fantasy is that she says she hasn’t
found the doctor with the right touch. Yes, that’s it. It’s not that the doctors can’t
do it. It’s that the doctors can’t do it in a way that avoids pain. She says the pres-
sure on each of the cysts has to be just right, and in my thoughts I get the impres-
sion that it is I, who will be the one able to put exactly the right amount of
pressure to each cyst on her back, because I’m so in need of her, I so empathize
with her, that I can sense exactly what it is that she needs.
“And so we’re in her bathroom or in her bedroom-it changes in my mind from
time to time-and I’m not sure how it transpires, but I begin to persuade her to let
me try. I just begin to try and she permits me. And then different things happen.
For one, there’s a scene where she is partially disrobed but holding her blouse or
sweater against her breasts. I tell her that that’s not important now because we’re
concentrating on more important things. So, she drops the clothing and leans
over. I see her breasts. They are modest, but merely seeing them is not what
makes me happy. Because it’s not about sex at this point. It’s about my happiness
in helping her and in her permitting me to get this close and intimate with her. It’s
about spending time together. She’s giving me her time and sharing with me–and
only with me–her most personal concern. And when I’ve helped her and broken
all the cysts and thus when I’m successful with her, we then get even more inti-
mate, but still not sexual, and in my fantasy, I then run a hot tub and gently lower
her into it. You see, she has to soak so the cysts will continue to drain. The cysts
are full of pus and they keep draining. And because of that she’s in my hands and
we need to be together, working on this problem and curing her, purifying her,
emptying her of all that pus. And then the fantasy switches to another variation of
the theme because the intimacy has been satisfied. But now something more, or
even more important needs to be satisfied.
“What I do in this next version, is make a template of the scores of cysts and
pus- sores on her back. At first the template is on paper which I’ve placed on her
back in order to trace the exact location of the sores and cysts. Then I somehow
transfer the paper template to a large board that now contains the exact map of the
sores and cysts on her back, both with respect to size and circumference of each as
well as the distance of one from the other. If you place the template-board on her
back, all the sores will peek through their respective holes on the template. Then in
the fantasy, I place her on what could be a massage table, and the template board
for her back is the surface upon which she lies, so when she lies down, all the cysts
and sore-like pimples will fit directly into their respective holes. Then as she lies
on her back on the table, the weight of her body pressing down begins to naturally
cause the array of eruptions through the holes. Under the template are balloons
attached to each hole so that when pus drains from each site, the pus then collects
into its own cyst balloon. None of it is wasted. Not a drop. It’s all collected.
“Then when that’s done, I sometimes have her soak in the tub for a time
while I stand at the tub and watch her soak. I’m slightly bowed looking at her
and we’re talking. And she is naked in the tub. And she is becoming accus-
tomed to me seeing her in her nakedness. And the fact that she becomes
accustomed to me seeing her like this is also very satisfying. It means that she
is relaxed with me even though she is naked. Therefore she is more intimate
with me than with anyone else. Oh yes, I also pop the cysts with my hands and
I wear rubber gloves in the fantasy. I’m never doing it with bare hands. Then I
have her stand, and I go to work again because after soaking in this hot bath,
more pus has collected, and then I finally push the rest out by pressing my fin-
gers against each cyst. This time even more pus is emitted and the final amount
gushes out of each cyst giving her tremendous relief as if pounds of weight have
been lifted. Then, out of sheer love for me, she falls asleep naked in my arms, in
bed. This part of the fantasy then fades, as though I’m spent. It’s not like an
orgasm or a sexual feeling, but it’s a feeling of relief and a satisfaction that I get.
At that point I no longer need to continue the fantasy. I find that I then go about
my normal life until another time, when the fantasy returns and I go through the
same thing again. And it happens all the time. And that’s it. But it’s not it,
because, believe it or not, I’m celibate and that’s how it has always been. I’ve
never had a sexual relationship.”
He then indicated that he hadn’t seen this woman in the past year but had heard
from others, who had seen her. After he heard that she was in touch with others in
the parish, he related the following:
“Since then, I started to think of actually having sex with her. I broke through a
barrier there. It’s the typical missionary position and we are in passionate sex.
I can see her face is quite sexual and her expression is that of a woman in the
throes of an orgasm. This is when I feel she’s mine.”
After relating this new development regarding the fantasy of actual sex with
this woman he indicated that at that point in the fantasy, the intrusive thought, or
the intrusive scenario, was getting the best of him and that it really was out of
control. He was thinking about it all the time.
“I think about it every day, even several times a day. It’s obsessive. I can’t
figure out when it will appear or why. Now it has me worried more than ever. And
even more than the sex–I can understand the sexual part–but why am I thinking
about cysts and pus?”
He also then repeated that it was after she married that he gained all his extra
weight, and he remembered a dream. He said, “All I remember of the dream is a
fragment. She said to me, ‘Well, you just have a hunger for me.’ ” And I awakened.
Now I know it means just that–I have a hunger for her. The fact is I’ve gained more
than 40 pounds over a three year period. My appetite knows no bounds. And she
married three years ago also. At 5 feet 9 inches, I usually weighed 165 pounds.
Now I’m 230. I look at myself and I’m horrified.”

Although the symptom and its embeddedness in an elaborate fantasy seems fan-
tastical, nevertheless the symptom itself is bound by the three constituents of the
symptom-code: the wish; repressed anger; and the who. These are the compo-
nents of the code, that when applied, will reveal the meaning of the symbols and
action of the fantasy–actually reveal the meaning of this patient’s magnificent
obsession, this rhapsody, which had so tortured him.
The important questions were: (1) what was his basic wish; (2) who was the
who toward whom he was angry; and (3) why was the anger repressed? It was
predicted that once these questions could be answered, and once he did something
related to the original problem, at that point the symptom would be severely chal-
lenged, and might be entirely eliminated from his experience, from his life.
The who seemed to be the best place to start. Since he was so fixed on this
woman, and could not focus on anything or anyone else, it seemed that to first
consider her as the who toward whom he was basically angry, would be a good
bet. Yes, despite his avowed love for, and esteem of this woman, the hypothesis
that seemed most valid, was that given his symptom he was probably angry or
even furious at her–unconscious though these feelings may have been. Of course
he would not at all be in touch with such feelings, especially because he was so
enthralled with her.
Thus, the identification of this woman as the who was a reasonable guess, and
the repression of anger toward her, was also assumed as a given. The wish
remained as the psychological key to the entire symptom problem. What then
could the wish have been? Actually, this was not really a mystery.
His wish, of course, was for her to love him. It was as simple as that. Certainly, on
top, more or less consciously, he wanted her to love him. Under it, however, because
she didn’t respond in kind, then he felt his wish to have been frustrated, unrequited,
thwarted. And it was a terrible feeling of disempowerment for him, if only because his
wish was so very strong, so very intense. This was the respect in which he felt disem-
powered, and the natural reflex of anger could not be acknowledged consciously.
Therefore, his only alternative was to repress the anger. The anger was then directed at
the self and since the wish also was represented in the unconscious, then presumably
he at once developed the symptom of the intrusive thought–the scenario of cysts
and so forth.
Apparently, his wish was gratified by the expressing of pus, an important point.
In his fantasy, she permits him to accomplish his aim, and then he feels relieved.
She gives him access to her naked body, but that is not the central point, though it
is a contributing factor in his gratification through the symptom. In fact, in
describing his elaborate fantasy, he emphasized that his true and complete relief
only came when his aim was accomplished –when he finally got all the pus out.
Applying the symptom-code reveals first that his wish was for her to love
him, to give to him. Second, this also means that she was the who. Third, by
deduction, when his wish was thwarted, he became angry at her and then
repressed the anger. What remained was the meaning of the symptom and its
relation to his elaborate fantasy.

Of course there are symbols throughout the fantasy, but the focus here will be to
target only the spine of the fantasy and not any secondary considerations. What has
already been implied, teased out here, is that he was angry at her but that also his
wish was indeed satisfied, albeit in perverse form, by way of the symptom. The
symptom was really symbolized by getting pus out and saving every drop of it in
balloons. Everything else, including tracing the cysts on her back and making a
template was done in the fantasy only so the crescendo of getting the pus out and
saving every drop, would be reached. It was only then that he felt truly satisfied.
Even though her trust in him was a source of solace, for example, in her acceptance
of him standing by the tub watching her soak, nevertheless this was not the sine
qua non or essence of the symbolic gratification of his wish. It was close, but not
yet a fully flowered and fully satisfied aim. That true aim was accomplished with
the extrusion, draining, and collecting of the pus to the very last drop.
To understand the symptom, the extruding pus collected to the last drop needed
to be related to this wish for her to love him. This was the key to the entire sym-
bolic nature of his elaborate fantasy construction–to connect the wish with the
extrusion of pus–which in a short-hand way, resulted in a symptom called an
intrusive thought.
Since the wish was for her to love and to give to him, the question became,
what is one process through which a woman gives? What is one way a woman can
give both symbolically as well as actually? She deprived him, but deprived him of
what? The answer with respect to an analogy may lie in the psychoanalytic under-
standing of the language of dreams. For example, in dreams sometimes things are
backwards or opposite. Up can mean down, in can mean out, young can mean
old; so too with symptoms. Thus, the law of opposites can apply in symptoms as
well as in dreams. And just as the law of opposites in dreams presumably dis-
guises the true meaning of the dream, so too does this same law act to disguise the
meaning of the symptom in the overall sense, as well as the meaning, specifically
of the wish.
Therefore, in this person’s fantasy, with respect to the drama unfolding on the
woman’s back, it may be highly likely that the real drama was on the woman’s
front–the opposite of her back. Thus, all the pimples or sores or cysts on her back
were really on her front. What do such configurations look like? Well, in his fan-
tasy he described the cysts as crater-like and red, and that they had a head to them
where the pus accumulated.
When confronted with this picture of the front rather than the back, as well as
his original rendition of how the pimples and sores looked, the patient practically
shouted, “It’s nipples. It’s nipples. I’m thinking about her breasts. That’s what it’s
all about.”
He was right. He was thinking about her breasts, and the focus on her back
was a psychological shift, a disguise. The question now became why was he
thinking about her breasts? And apparently the answer was concealed in his feel-
ing that he was being deprived; that is, even though she liked him, and was
friendly with him, nevertheless, she never demonstrated anything other than that.
This left him feeling unrequited. His wish was that she be giving to him and that
meant symbolically, that her breasts would give milk. And this explains why he
needed to collect every drop of the pus–because the pus was a most ingenious
disguise for the milk. Since every drop presumably represented her milk, then in
the fantasy, the symbol of the pus, and the importance of collecting it, meant that
she was giving everything she had to him–her milk; that is, she was giving him
all of her love, concern, nourishment.
Thus, when he got all of the pus out, that’s when he felt true and complete
relief. Only then did it mean that she gave to him the maximum love and nurtu-
rance that she had to give. And she gave it only to him; not to the doctors. In this
sense he was right, the entire fantasy was never about sex, it was actually about
acceptance. He just wanted to be accepted by her.
Yet, he couldn’t have his wish in real life, and so he had the wish in fantasy in
the form of a symptom. It was an obsessive-intrusive thought that got a profound
grip on him which he couldn’t shake. In fact, it was shaking him. And the scores
and scores of cysts and pimples on her back represented a multitude of nipples
also reflecting the truly desperate nature, as well as magnitude of his yearning and
need for her.
So far as his obesity was concerned, this also related to his overwhelming focus
on this woman. It could be said that he was eating because he couldn’t be without
her; that is, he couldn’t be empty or alone. To constantly eat, meant never to be
alone. In addition to his gluttony, he also stated that in his present life, there was
never a time that he didn’t feel bloated and this bloated feeling was seen to signify
that this woman was always with him. She was the who, and since he was presum-
ably so angry with her for depriving him, then he was also really medicating him-
self with food to assuage the anger, to calm it. In effect, he was actually afraid to be
hungry because his empty stomach, his hunger, possibly, would signify that he was
without her. Further, he remembered the fragment of his dream in which she said,
“Well, you just have a hunger for me.” Thus, if he was full, he wouldn’t have to
know he had a hunger for her. In this sense, the wish to have her was always
fulfilled by being full, by being bloated.
It also seemed that he would do anything but admit to himself that he was
really angry at her for ignoring him and for leaving him and marrying. He would-
n’t and couldn’t face this feeling because it would mean that he didn’t have her
and perhaps never would.
All the symbols involving symptom, cysts, appetite, and stomach, that had so
much power over him, had now, in the light of this deciphering increased his con-
sciousness and seemed to have a profound effect on him. It was unlikely that the
symptom could ever again become viable. However, in order to fortify the defeat
of the symptom, the last task he needed to accomplish was something that related
to the relationship that he had had with her. This doing activity would bring him
in front of The Line, and enable him to burn away the inclination to live behind
The Line in withdrawal where his magnificent obsession/elaborate rhapsodic fan-
tasy lived and thrived, and kept him in a sustained state of high tension.
His answer was that they had worked together on a catalogue for the gifts
given to the church but never finished the catalogue because they were working
on it at the time she married. She never returned, and he avoided the task of
completing the catalogue. Now, perhaps he could get back to it.
But he wasn’t finished. He said that not only did he overeat, but he had food
cravings, and that these cravings for certain foods was a frequent occurrence. He
felt this was a separate symptom even though it may have been related to the entire
rumination about this woman. The meaning of his large stomach requires a bit of
speculation, the relative validity of which, nevertheless, is based upon an interpre-
tation consistent with the data he provided, and in addition reveals a possible path
to understanding this symptom–his large stomach.
The fact was that he had a big stomach on a rather stout frame. He carried his
weight well except for this big protruding stomach. He actually looked pregnant,
and since there was so much repressed anger directed at his woman friend for her
depriving him, then the only way to express a likely interpretation to him, so that
both his anger and his attraction to her would be contained in the same word,
seemed to be the choice of the colloquial term “fucked.” It would seem that he felt
fucked by this parishioner. So what happens when you get fucked? You get preg-
nant! By virtue of this sort of interpretation, it could be construed that his big
belly was his pregnancy. Symbolically, he may have been carrying the product of
his lady friend’s essence in his belly. His gluttony therefore, was his perversion.
It too, represented the pleasure he wanted from her but couldn’t have, and so he
had it another way. And furthermore, perhaps he acted out the pregnancy with
food cravings. This can be considered a content-shift, that is, a shift from the
internalized object, the woman, to food. In the psyche, as Freud postulated,
wishes are never denied. This man wished for her, and in his psyche got his wish.
Symbolically, therefore, being pregnant with her meant that he wouldn’t have
to face life without her. Of course, in bleak reality, he actually didn’t have her.
What he had was a fat stomach, and a magnificent obsession.
Chapter 10
Ingenious Regression:
A Case of Hallucination
A woman of 60 had been in an assisted living environment for her entire adult
life. Over the years she had consistently scored in the I.Q. range of 65 to 70. Such
scores placed her in the category identified as “mild deficiency.” In the more anti-
quated I.Q. language, she would have been classified as retarded.
The mild deficiency designation meant that she could work at a job, especially if
her tasks on the job were structured, and if they enabled her to perform in a repeti-
tive and consistent fashion. And indeed, throughout her adult life, she was always
employed in one way or another, within the context of a variety of programs that
could be defined as “assisted abilities” programs.
This woman had two siblings, a brother and sister, who were never very
involved in her life, and would only visit occasionally–a family interest on their
part that was perfunctory. Her mother, age 97, was still living and surprisingly,
quite active. She was a devoted visitor, and would escort this woman, her 60 year
old daughter, home for holidays and for other special occasions.
This mildly deficient woman, was hardly ever ill. In fact, her health was
excellent, and she was quite proud of the fact that she had never missed a day of
work. Her only identifiable problem was that she was obviously, and severely,
dependent on her mother, and would make decisions only with her mother’s say
so. All of her clothing, and all items and materials she needed, were provided
solely by her mother.
Suddenly, at the age of 97, her mother died. She had expired in her sleep. After
having been told of her mother’s passing, this woman became quickly withdrawn
and depressed, and for the first time that anyone could remember, she stopped
working.
“Devastating,” would be an apt adjective to reflect this woman’s state of being
after she had been informed of her mother’s death. The loss was apparently so
profound and her depression so deep, that she stopped eating, and would lie in
bed, moaning. She was hospitalized and diagnosed with major depression
Within one day of hospitalization, and even before any plan was made for
medication, her depression lifted, and instead, she was floridly hallucinating.
She began talking to the air as well as providing dialogue by answer.
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68 10. Ingenious Regression: A Case of Hallucination

During the first consultation, she continued talking to, and answering the air, as
well as relating to the examiner, and did it all with relative ease, and in the absence
of any depressive mood. She never grimaced or in any other way showed any
trace of schizophrenic mentation or behavior. The only exception with respect to
psychosis, was the presence of the auditory hallucinations that, it seemed, had
entirely usurped her psyche. Her depression was nowhere to be seen.
“He told me I’m ‘independent’; he said, ‘independent.’ And that I shouldn’t
worry. And that I could take care of myself now. He said he was sure.”
This quote was a reference to the psychiatrist who initially conducted the
intake interview. Apparently, what had occurred was that in an effort to reassure
this patient and to try to be encouraging, the psychiatrist told her that now that her
mother was deceased, that he was sure she could handle things herself. This psy-
chiatrist’s thinking was that if the patient felt reassured about her abilities then
perhaps she would feel less depressed or less lost.
Although the psychiatrist was trying to be supportive–commendable, no doubt-
but as it turned out, not insightful. The problem was that the psychiatrist did not at
all understand what had happened to the patient. The patient’s concern was about
her lost object, her mother, upon whom she so depended. She was devastated that
her mother was gone. For the patient’s entire life, her mother was the person upon
whom she was dependent for anything and everything.
Although, in this initial consultation, the various events that had occurred since
she learned of her mother’s death were reviewed, nothing could explain her
dramatic shift, after she was hospitalized, away from depression and into a hallu-
cinatory world. The only intervening and possibly important event seemed to be
this exchange between the patient and the intake psychiatrist.

Without the use of the symptom-code to unscramble the mystery of her shift from
depression to a psychotic hallucinatory state, it would have been extremely diffi-
cult to know where to start. Yet, by applying the symptom-code to this problem,
the mystery instantly yielded.
It was assumed that the intake psychiatrist was the who. Of course this meant
that the patient was angry with him, but that the anger was repressed. In addition,
and parenthetically, the assumption was made that perhaps in the unconscious,
retardation or even mild deficiency, are not relevant phenomena. Even those
people who have lower I.Q. scores still demonstrate conventional psychological
symptom formation. This implies that whatever psychodynamics operate to pro-
duce psychological-emotional symptoms in people of average or above I.Q.s, must
also, by definition, operate with people of below average I.Q.s. Thus, symptom
formation, it is proposed, only follows rules of the psyche – and not necessarily
solely rules of biology.
Of course, as stated, it was assumed that the patient must have repressed a great
amount of anger. This was assumed because a profound shift had taken place in her
psyche, most likely concerning the management of this proposed repressed anger.
This shift could be characterized as the transformation of a thwarted wish into a
hallucinatory symptom. With respect to the structure of the symptom-code,
this repressed anger necessarily induced transformation of the thwarted wish into
the hallucinatory symptom because, according to the Freudian insight regarding
wishes, her wish needed not to be denied. The simple question became, what wish?
In other words, the unconscious process that took place consisted of the transfor-
mation of the wish through the repression of anger, into the symptom–in this case a
hallucination. The patient’s basic wish would necessarily be part of this process
insofar as the wish always, and presumably without exception, becomes satisfied as
the symptom. Therefore, her hallucination became her gratified wish.
Again, the question remained as to the specific meaning of the wish. What was
her wish? The answer was that her wish was simple and actually even obvious.

It seemed likely that the key to the understanding of the symptom was in the
exchange that the intake psychiatrist had with this woman. He told her that now
that her mother was gone, she surely was able to take care of herself; that she was
a grown up, and could be independent. The problem was that the psychiatrist,
despite his good intentions, apparently lacked the insight to see that what this
woman wanted most, what her basic wish was, was not to be independent. She
wanted her mother, and she wanted to sustain her life long condition–to be
dependent on her mother. Her wish was to have her mother not be dead. Her basic
wish, was to have her mother be alive—period; a positive wish.
In a deeper psychoanalytic sense, it could be assumed that because of this
woman’s life long dependency on her mother, that at an unconscious and deeply
repressed level, she harbored resentment toward her mother, and this may have
been so, precisely because of her all-consuming dependency on her mother. The
ubiquitous principle governing such an assumption is: dependency breeds rage.
Thus, were it not for the perhaps fortuitous intervention of the psychiatrist, her
depression may have given way to other more serious derivatives of depression,
namely, chronic despair, or even suicidal implications, from which any remission
could be highly doubtful. However, the entire depressive picture shifted to an
hallucinatory process culminating in a florid hallucinatory symptom. If, in fact,
this was the case, then it could have happened because whatever anger she may
have been harboring toward her mother, both as a function of her chronic depend-
ency, as well as because of the abandonment feelings that death confers, may
have transferred to the psychiatrist.
It was the intake psychiatrist who very probably became the object of her
anger, her who. And then this woman who was essentially considered retarded,
demonstrated her rather high unconscious I.Q. by proving the psychiatrist wrong.
70 10. Ingenious Regression: A Case of Hallucination
He said her mother was dead, and that she, the patient, was now independent. But
she showed him that she was not at all independent, that she was still dependent,
and quite dependent for that matter, on her mother, who now in the hallucination,
was very much alive, indeed!
She brought her mother back. And it was a simple regression into a hallucination
that did it. She was now floridly hallucinating – that was true. But it was her mother
to whom she was talking, and it was her mother who was talking to her. Hence,
everything was good with the world. No more depression, no more abandonment,
and most importantly, and thankfully, no more independence. The psychiatrist, was
wrong on all counts. Dead wrong!
To relinquish the hallucinatory symptom as well as the depression this woman
would need to be involved in some doing activity related to her work. It would be
an attempt to reinforce in front of The Line living. For her to understand the wish
and the anger also seemed possible, especially as a prelude to the cure of her
symptoms.
The rather astonishing result here, is that this I.Q. challenged woman devel-
oped a symptom that involved a complex unconscious regressive psychological
maneuver. It was a maneuver, nothing short of brilliant, involving a positive wish
that generated a shift out of despair and depression, via a hallucination, into emo-
tional relief of tension. Thus, she developed what might be called an ingenious
regression, and consequently the symptom of a brilliant hallucination.
Chapter 11
Panic on the Bridge:
A Case of Agoraphobia
An immigrant man of 35 sought treatment because he would become panicky and

“break into a sweat,” whenever he was driving across a bridge. The immediate
effect of this problem concerned a small moving business that he had recently
established. He was now transferring people and their possessions from place to
place within the city. But he would not accept a job if it required him to drive
across a bridge. Although this problem did not make it impossible for his business
to succeed, nevertheless, he found himself occasionally turning down work
because of it. His problem on the bridge was about the span of the bridge; that is,
that it became a problem if the bridge had a distinctly elongated span over water,
and therefore, gave him the sense, he said, “like nothing was good, like it was too
open.” He was also afraid of the water.
On his latest job, apparently he mistook the client’s instructions about the des-
tination, and found himself heading onto a bridge which led from one part of the
city to the other. There was no way for him to reverse his direction, and because
of the congested traffic, he felt it would be embarrassing for him simply to stop.
He only made it across because apparently, at some point on the bridge, all traffic
slowed to a snail’s pace, and his passenger, who became aware of the driver’s
problem, insisted that they switch seats. The patient was only too glad to do so.
Now, the passenger became the driver.

His description of his reactions during this episode made it clear that what he
experienced was anxiety and even perhaps panic. As it turned out, this man had
been suffering with this symptom for the past five years; according to him, from
the time he married. This latest incident of feeling panicked on the bridge when
he was the driver, caused him palpitations, and he “broke into a sweat.” He
described the symptom as one in which he was shaking, and also felt light-
headed. It could be assumed, at least from his description of his breathing, that his
light-headedness was perhaps a result of what seemed to be also an episode of
hyperventilating. His description of his behavior during this traumatic event,
71
72 11. Panic on the Bridge: A Case of Agoraphobia
temporary though it was, sounded as though he had had a bona fide anxiety or
panic attack, which he claimed, “was like the others.” He had experienced these
symptoms before.
When they had driven over the bridge, rather than continuing on their journey,
the new driver exited at his very next opportunity, and retraced their route, taking
the patient back over the bridge, and home. As it turned out, the driver was
expecting more of the same kind of episode from the patient on the return trip, but
the patient explained he only became anxious when he was the driver.
The patient described his therapy experiences of the recent past. He had been
treated by two kinds of therapy. The first was strictly a medication regimen con-
sisting of drugs designed to alleviate anxiety and panic. The patient discontinued
the use of such medication when it became apparent that his libido was severely
affected and as a result, he was less able to feel amorous, or to be sexual. His wife
also insisted that the medication was not right for him.
The second round of therapy consisted of a behavioral-cognitive approach in
which the therapist attempted to desensitize him to bridges, but with no success
whatsoever. From a psychoanalytic point of view, and despite reports of success with
such methods, this behavioral-cognitive approach would not at all be considered effi-
cacious, because the problem is not literally about the bridge. Psychoanalytically, the
bridge would be considered a symbol, and the main objective would be to try to
understand what such a symbol meant.
The patient explained that he came from a large Pakistani Muslim family in
which he was the oldest of his siblings, and closest to his mother. He was also the
one most eager to stay close to his family. He admitted to being devoted to his
mother, but also to loving his wife. He felt that he was persuaded into his mar-
riage by his wife, all the while experiencing great ambivalence.
“I didn’t want to hurt her and she wanted to marry me. I did love her, but I
didn’t feel I could do it yet. I wasn’t ready. But I did it.”
He admitted to still feeling uncomfortable with his wife in their rather small
apartment, although he professed that he did love her and was happily married.
They had no children because has he put it, “I don’t feel ready yet to have
children.”

The process, in this present therapeutic situation, was to apply the symptom-code
so that he could make conscious that which was presumably unconscious. That is
to say, because he was so affected, and even controlled by this symptom, he nec-
essarily must have been harboring repressed anger. It was further assumed that
the anger was repressed because he was not able to direct this anger to its
intended object–the who. Correspondingly, it was the who, the person with whom
he was angry, who would have been the person to have thwarted his basic wish.
Thus, the details that needed attention concerned the identity of the who, in addi-
tion to ascertaining his basic wish.
This man’s symptom seemed quite compartmentalized. Although it had been

causing him distress, and even interfering, especially with his business life, never-
theless he had kept it isolated, and the symptom itself had apparently never insin-
uated itself into his amalgam of character traits where it could have usurped the
personality. On the contrary, the symptom had remained encapsulated, as it were,
within the organization of his personality. The fact was that the symptom was still
alien to him despite its five year existence. Thus, it would be expected that on the
basis of its alien nature alone, this man’s symptom, indeed, would be subject to
the talking cure.
It needs to be acknowledged, however, that the more chronic the symptom, the
more resistive it becomes to the talking cure. The symptom described here, with
respect to its life-span, to its relative longevity has gained some traction and
become an iffy proposition, not with respect to cure itself through psychotherapy,
but more with respect to efficient cure through psychotherapy. The point is that in
this case, with regard to prediction, the issue of cure was not expected to be the
crux of the matter. Rather, the issue was expected to be an empirical one. In other
words, would the patient respond to the treatment with the use of the symptom-
code so that the symptom itself would lift rather quickly, or, because of the rela-
tive entrenchment of the symptom, would it turn out to be somewhat more
difficult to cure? That was the essential question.
One thing was certain, his problem was not about his fear. Phobia, is never
about the fear! In any event, it is almost impossible to reason with the kind of irra-
tional fear that is characterized by a phobia. The real problem was about his
repressed anger toward a person who had compromised his wish, and his conse-
quent panic represented his wish realized, albeit in perverse form–the basics of
the symptom-code, the wish, the repressed anger, and the who. The coda to the
symptom-code, the doing – that is, his doing something regarding the original
thwarting of his wish, would be the something to decide upon when the uncon-
scious conflict became conscious, and very importantly, if he was able to come to
grips with it.
Because of his admitted dependency on his mother, it could be hypothesized
that she was the original who. But actually he was not very focused on her, and
hardly referred to her. He also didn’t say very much about his father or about his
siblings. Rather, he kept focusing on his wife, his marriage, his love for his wife,
and his original ambivalence about getting married. This was the subject matter
that interested him. It was where his tension was focused, and so his wife was a
very good candidate for the who with whom he was basically angry, though
unaware of it. His love for her was believable, but what he apparently didn’t
understand was that it was possible to love and be angry with the same person,
and that moreover, an emotional coexistence of that kind is all right, even normal.
Apparently, he felt that to be angry with the person you love is equivalent to some
kind of sin, and being aware of it, conscious of it, might therefore make him out
to be a bad person.
It seemed that his wife was the identified who, and his repressed anger was
about her. Furthermore, to understand his wish was also uncomplicated. His wish,
five years ago when he married, was not to marry. Ambivalence is a tricky state. It
seems to mean that you may want to do something and then again, you may not
want to do that thing. Yet, ambivalence is never democratic; each side of the
ambivalence does not get an equal emotional vote. The fact is that in ambivalence,
the “no” vote is dominant. When the “yes” vote brings to bear pressures from
other sources that subdue the “no” vote, then the person will indeed be able to
engage in the action about which the ambivalence was originally concerned. In
this patient’s case, when his “no” was subdued or outvoted, he did indeed engage
in the action about which the ambivalence was originally concerned. He married.
His wish was not to marry. Yet, he did marry, but he seemed also to have married
his ambivalence.
In this patient’s case, his marriage, one might say, was based against his stronger
ambivalent “no” vote, and in favor of his weaker, ambivalent “yes” vote. He had
been suffering the consequences of that “yes” vote up to the present time with the
symptom of selective agoraphobia. He was not phobic about just any open space;
the symptom only appeared with respect to crossing bridges.

His wish had been not to marry yet. His wife became the who toward whom he was
angry because of her power to sway him against his wish. Thus, going against his
will, or his wish, disempowered him and then this disempowerment generated the
anger that he repressed. He would have then correspondingly, developed this ago-
raphobic symptom based upon the definition that the symptom is the thwarted
wish, fully realized. In some way, the agoraphobia would have had to be a sym-
bolic reintroduction of his original ambivalence regarding his marriage.
Now, how does being panicked, and in the throes of an anxiety attack that gen-
erates the full flower of a compartmentalized phobia, satisfy one’s basic wish not
to marry yet? The possible answer to that question invites a psychoanalytic per-
spective of the symptom within the context of the symptom-code.
First of all, the symptom-code cannot answer each question directly. At times
the code can lead to the bridge, but to get across, sometimes one needs a touch
of the Socratic method. In this sense, the question becomes: What does a bridge
do; that is, what purpose does it serve?
It may be that to understand the answer to that question is also to under-
stand the meaning of the symptom. Of course, such meanings are educated
guesses–hypothetical. The concern here is in the search for the truth of the
interpretation–for its validity. With the reasonable certainty of the interpretation,
it becomes more possible to make the unconscious conflict, conscious. Then, the
mystery of the symptom that so defeats the patient with its otherworldliness and
irrational existence, can be seen to be quite prosaic. In fact, it is probably the case,
that no matter how bizarre a symptom seems, when it is unraveled, it is usually
then seen as being basically simple. It becomes no longer something mysterious
or to be feared, and certainly no longer other worldly or irrational. When it is
unraveled, the symptom loses its power, and so its reason for being will usually
cease to exist. So too, it was expected that with this patient, the bridge phobia
would, for all intents and purposes, vanish.
So what does a bridge do? A bridge usually connects two bodies of land mass
that without the bridge, would in an anthropomorphic sense, find it difficult, even
impossible to be connected, that is, to relate-and in a real sense, without the
bridge, these two land masses remain distinct and unconnected.
It could be that this kind of metaphor reflects the patient’s unconscious conflict
regarding the genesis of his relationship with his wife, from the beginning of his
courtship, to his initial ambivalence about marrying, to his marriage, and to an
ostensible repressed anger regarding what he may have considered to be, and may
still consider to be, doing something against his wish. The wish, of course, in one
sense, was to rid himself of his ambivalence, which he apparently could not do.
Thus, it could be assumed that he had carried this conflict with him to the present,
in the same configuration as it was in its initial state. Even though five years had
elapsed since his marriage, nevertheless, in his psyche it is quite likely that the
conflict with its derivative product of ambivalence about marriage, remained the
same, intact, with time having no effect on it. The phenomenon of transference is
a supportive underpinning to this notion of the possible stasis of psychic conflict,
or of the resistance of psychic conflict to conditions of the real world. Of course,
particular transferences can last a lifetime without any changes to their nature
whatsoever, no matter what kinds of experiences the person has.
Thus, it may be that his bridge difficulty was really a difficulty in an unresolved
conflict regarding his stated ambivalence that reflected isomorphically what he
originally felt about marriage, five years earlier; that is, a tension about the bridge
to marriage, and a corresponding tension about bridges that connect one land
mass to another. Of course, assuming that these constituents of the symptom-code
did, in fact, faithfully represent what was transpiring in his psyche, then:
(1) knowing that his wife was the who; and (2) knowing that he was angry at her
despite the fact that he also loved her; and (3) knowing that his phobic reaction to
bridges really was a psychological equivalent to his five-year-old ambivalence;
and (4) therefore, that the phobia itself, notwithstanding its selected and compart-
mentalized nature, was an ingenious realization of the part of the ambivalence
that comprised his basic will–namely, not to marry against his wish; then, (5) it
would be expected that the symptom itself would be seriously challenged, and
perhaps dealt a death blow.
At such a point, in the symptom treatment, a doing thing would be important to
implement. In this man’s case the doing thing was seen to be some attempt on his
part to surface a discussion with his wife about the entire issue of his ambiva-
lence, and simultaneously to be sure to assure her that this ambivalence had noth-
ing to do with his love for her. He would need to emphasize that the ambivalence
was about his problem, his psyche, his history, his transference’s, his early family
life, and whatever else it suggested about his capacity to be ready for a departure
from his nuclear family–before he and his wife ever even knew one another. Such
a doing activity would surely nullify his behind The Line withdrawal with respect
to the dynamics of the symptom concealed within his withdrawal – a withdrawal,

so to speak, that because of its non-clinical nature, is hidden in plain sight.
In addition, the fact that his wish was negative, that it was an avoidant or indi-
rect wish–that is, not to marry as a response to the powerful negative vector of his
ambivalence–necessarily meant that it could be predicted that the symptom itself,
rather than producing relief of tension, would instead, sustain or increase his ten-
sion; and that is precisely what had happened. His anxiety and panic regarding
bridges apparently congealed into a selective agoraphobic reaction which only
became ignited when he himself drove the vehicle. When others drove, none of
this symbolism was evoked because as a passenger, his role as a decision maker
was nullified.
Now the phrase “panic on the bridge” was revealed not to be about the steel, or
girders, or span of the bridge at all. What it was really about was the steel and gird-
ers and span of the emotional bridge from the patient to his wife that, in addition,
spanned five years.
Chapter 12
“I Can Hardly Move”:
A Case of a Three-Day Migraine
The patient moved very slowly as he walked into the conference room of an out-
patient clinic. He was wearing sun glasses and said that the light bothered him.
However, it was clear that even with his dark glasses, he was squinting, and his
face was pinched with pain. He was a 60-year-old man who was experiencing a
three day migraine.
The room was filled with a dozen or so psychologists, social workers, and psy-
chiatrists. The report that was read to those assembled stated that the patient was
reassured by his physician that there was no physical basis for the migraine, and
that the pain was certainly emotionally based; a severe tension headache caused
by some psychological-emotional conflict.
This was not terribly reassuring to this man who had been suffering with the
migraine for the previous three days, without any relief. It was so bad that he
pleaded with his physician to get him some general anesthesia. He said, “I have
to speak softly. I can’t move too suddenly. It’s like a vice in my head.” He also
indicated that this same kind of head pain had occurred on two other occasions
in his life.
The report had also indicated that he was married with no children, and that he
was born partially deaf. As it turned out, the fact was that he was born almost
completely deaf, and this accounted for his awkward sounding speech. The crisis
of his life, at the time of this conference, was that he and his wife were in finan-
cial straits. Apparently, he, along with many others, had been excessed from his
job during an ongoing recession.
Since the migraine had appeared only three days earlier, it seemed unlikely
that the direct pivotal stimulus for it concerned his job loss, which had happened
more than two months earlier. However, because of his job loss, this couple had
incurred a sizable amount of credit card and other debt, and it was then that the
patient began to feel depressed. “We had to change our lifestyle immediately,” he
said. “I only feel depressed about this situation. Otherwise, I’m not depressed,”
he added.
77
78 12. “I Can Hardly Move”: A Case of a Three-Day Migraine

The initial consultation was followed by a smaller meeting because the patient
was bothered by the larger meeting. In the first consultation the patient had
told the assembled staff that because of their financial condition, his wife and
he would now need to live with his wife’s affluent sister, who lived in the Deep
South. The plan was that the sister would take care of all financial matters.
However, the patient was adamant about not wanting to go. “Even though
we’ll get a subsidy, and won’t be paying any rent, and she’ll pay all of our bills
until I can find a job, I still don’t like it,” he said. He paused for a moment, and
in an expostulation of anguish and protest, he further said, “I hate it, and I told
her so.”
Upon further investigation, the patient revealed that he was a member of one of
New York City’s oldest private clubs. He was particularly proud of the fact that to
gain membership in the club was quite difficult, requiring recommendations as
well as some evidence of distinguished work in a given professional field. Thus,
the membership of the club consisted mostly of persons of letters, professors,
politicians, entrepreneurs, and so forth. The patient gained entrance because he’d
been active in community affairs, and had been on the Mayor’s volunteer commit-
tee to tidy up the parks of the city. He had been the one to organize the fund rais-
ing for shovels, pick-sticks, rakes, and various other such items. The club, he said,
was very important to him. Apparently, membership in the club elevated his sense
of self-esteem, and, in addition, gave him an overall sense of achievement, and, he
added, “even emotional security.” It would be all for naught, he claimed. He was
leaving.
The patient’s objection to leaving led to an intense argument with his wife, who
kept repeating to him the need to leave, with which paradoxically, he agreed. He
knew it was the logical thing to do So, on the one hand, despite the fact that he
knew the move was the only way to salvage themselves, on the other, he was still
adamant about not wanting to go.
He was also quite clear about his hearing challenged condition, his hearing dis-
ability. He indicated that in the club, and for the first time in his life, no one cared
about the way he spoke. Apparently, when he was a child, other children would
occasionally imitate his somewhat awkward sounding speech. “It imprinted itself
on my soul,” he said. “But at the club no one cares about how I sound–they’re
only interested in how I think. And when it comes to thinking, I’m fine.”
Many questions were being raised by members of the staff, and the session
was becoming somewhat of a free-for-all. The patient complained of too much
noise, and it was then that it was decided to meet in a smaller conference room
with only three of the staff. The larger meeting adjourned, and the patient was
escorted to the smaller room. It was in here that he further admitted to feeling
horrible about his impending move, and repeated that he forgets about his argu-
ments with his wife and starts thinking about how to actually manage and adjust
to his new situation. In fact, his wife and he had already made arrangements for
the transfer of furniture and various other of their possessions, and despite his
protest, nevertheless he was immersed in the reality–the considerable planning

regarding their relocation.
When pressed about the arguments, he recalled that he wanted to shout at his
wife, “I can’t go,” but instead, he “beat around the bush.” Then he indicated he
would forget the arguments because he was too busy with the details of moving.

At the smaller meeting, he was asked whether, even at the present moment, at
this meeting, did he feel angry at his wife? He denied this, but then remembered
that several days earlier he and his wife were talking and in the midst of their
conversation he had the fantasy not only of shouting at her, but rather screaming:
“I can’t move, I can’t.” He didn’t do it. Rather, he again said, “I just beat around
the bush.”
In applying the symptom-code, it was a good bet that his wife was the who, and
that not only was he angry at her, but more than likely, he was furious at her. The
fact was that again, even though he knew he was angry at her, it was only a super-
ficial knowledge. He was not at all aware of the extent of his anger, nor of its per-
vasive nature. His conscious thought about his anger was only that he was feeling
conditionally angry at her; that is, only when they had their arguments. It was as
if he felt that his anger had parameters; the anger started at the beginning of the
argument, and ended when the argument was over. Thus, even though he believed
his anger was time-limited, and even though he also consciously knew about
some of it, what he didn’t know was that much of this anger was in a repressed
state, and that without any doubt, it was smoldering.
His wish was also easy to understand. Most prevalent was his wish not to
move, not to relocate, not to relinquish his club membership. If the wish were
to be satisfied, then he could retain his reassured self-esteem, essentially
fueled by his membership in the club. And even though his wife was entirely
unmalicious in her zeal for them to seek refuge with her sister, nevertheless
the frustration of his wish was attributed to her. With respect to the content of
his unconscious, so far as he was concerned, his wife was responsible for his
many “d’s”–deflation, depression, despair, and demoralization, as well as
responsible for his many “dis’s”–disgust, dispiritedness, disorientation, and
dislocation.
The task here was to help him see that his anger was actually more pervasive
than he thought, and quite likely, that this anger was attacking him and was the
emotional culprit in the appearance of his migraine. When this interpretation
regarding the connection between his anger and his migraine was surfaced, he
tried to avoid its implication, but he would keep coming back to the point by say-
ing: “So you think I’m really always angry at my wife underneath it all, and that’s
why I’m suffering with the migraine?” The idea definitely arrested his attention,
and he couldn’t quite leave it alone.
80 12. “I Can Hardly Move”: A Case of a Three-Day Migraine

The special club he belonged to elevated his self-esteem. It was a compensatory
agent for him. The question became: Compensating for what? The answer it
seemed was that his membership in the club enabled him to feel whole, adequate,
and not concerned with being deaf or speech challenged. This was the essence of
the meaning of the symptom. The club meant adequacy. In his new living condi-
tions with his wife’s sister, he would be stripped of such compensatory currency,
and therefore perhaps at that point he would need to confront what he considered
his true reality–the misery of being inadequate, deaf, and sounding awkward
when he spoke.
Thus, the salient issue was joined. He must have felt that to have the killer
migraine was actually preferable to confronting this crucial issue of his life–his
deafness, his awkward speech, and his sense of profound unwholeness. It may
have been that with this new looming geographic relocation, he began to feel a
descent into oblivion, that all the taunts he had experienced as a child were jus-
tified and now even validated. Thus, it was better to writhe in pain for three
days rather than for him to confront the confounding problem of his life.
Feeling the killer migraine served to distract him from the consciousness of his
deafness, his awkward speech, and what he began to again feel – his other than
normal self. No club, no normal self–only awkward speech and problems of the
hearing challenged.
The upshot of this dynamic was that the presence of the migraine meant he was
still adequate. That is, so long as he was distracted from the symbol of his inade-
quacy, his hearing and speech, then he remained adequate–albeit with a severe
migraine. The migraine was therefore a displacement away from his deafness–a
gratification of his wish to be adequate. Since, in the psyche, no wish will be
denied, then by having the migraine, he got his wish–he remained adequate, and
in addition his indirect wish not to move, produced a painful symptom.
In the smaller meeting, when all of this surfaced, he suddenly began talking
without the severely pinched expression which had originally characterized his
demeanor. He then also suddenly removed his sun glasses, and exclaimed: “The
migraine is better. It’s not a migraine. It’s better.” He exclaimed that it felt like
geologic plates shifting; that is, he explained that in his head, he could feel as
though different planes were shifting.
His migraine was actually cured on the spot. This occurred by the sheer power
of surfacing the elements of the symptom-code and talking about them. He even
looked younger. It seemed that the curative process was quite easily achieved here
primarily because his anger toward his wife, the who, had not been at all heavily
repressed. Rather, he was conscious of his anger toward his wife but had felt it
was only related to his arguments with her. What he wasn’t aware of was the full
extent of his anger. It was at the point when he could see that his anger was all
encompassing and was entirely and continuously directed at his wife, that he
began to feel better. Then when it was interpreted to him that the migraine was
pretty much preferable to confronting the whole issue of his hearing and speech,
which he felt he was being forced to do by relocating and leaving the club, he
became silent, and seemingly thoughtful, and it was then that he exclaimed he
was feeling better.
In addition, it was suggested that he look into other clubs in his anticipated new
environment, and that also with the locating of a professional position, he could
create another productive venue, that in the end would serve him well.
Chapter 13
Doubled Over: A Case
of Displaced Phallic Obsession
This case was unusual in several ways. First, the patient had been seeing a female
therapist at an outpatient clinic, and only a chance encounter with him in the corri-
dor leading to the therapy rooms led to his fervent request for a change to a male
therapist. Second, he did not request this change of therapist because he was angry
or in any other way opposed to his therapist. Rather he wanted to switch because
he felt he couldn’t say things that he needed to say, “In front of a woman–a nice
woman like that.”
When I first saw this man he was kind of in a doubled-over position, arms hold-
ing his stomach, standing somewhat bent over in the corridor leading to the ther-
apy rooms. I asked him if he needed help and he squeezed out a “No,” as though
his stomach was in knots. He asked me if I was a therapist, said that his therapist
was late, adding, “She’s never late,” and finally then said, “I think I need a male
therapist.”
He claimed he had things to say, “something that’s not easy to talk about with
a woman.” After ascertaining that I was indeed a therapist, he asked me, on the
spur of the moment, and without much apparent consideration, whether I would
be his therapist. I suggested he talk it over with his therapist and then see how he
felt. Before I had the chance to explain it further, he started: “I get doubled over
all the time. It’s about beautiful women, you know–built. When I see one in the
street or anywhere, I feel like someone shot me in the stomach. It’s so fierce that
it doubles me over.”
I told him again that I couldn’t get involved, and that really, he should try to
talk to his therapist about it. He disregarded me and whispered: “It’s tits. They get
me right in the labonza. Know what I mean? I just double over. It’s like getting
shot with a shotgun or something. And it hurts. I’ve gotta tighten my stomach
muscles to get over it. What the hell is it?” He then pleaded with me to speak to
his therapist, which reluctantly, I agreed to do. He said, “Okay, but don’t say ‘tits’
to her. Say I said ‘breasts.’ But between you and me, breasts isn’t it. It’s tits! That
does it to me.”
At this point he was no longer doubled over. He had straightened up. He con-
tinued: “And you know that blonde secretary with the big ones down the hall?
Well she just walked past me right before you showed up. And you saw–I was all
83
84 13. Doubled Over: A Case of Displaced Phallic Obsession
messed up. I had to wait a while before I could straighten up. What’s causing it? I
can’t imagine what’s causing it.”
What he was saying was also reminiscent of what a patient I had treated some
years earlier had told me. That patient felt as though someone had just punched
him in the stomach whenever he saw a woman in a tight sweater who had large
breasts. That patient said it only happened when the woman was wearing a
sweater, and he associated the feeling of being punched in the stomach with anx-
iety. Of course, the anxiety was his conscious experience that was, in all probabil-
ity, radiating up from repressed anger.
“Doubled-over” interrupted my reverie by finally saying: “Listen, when you
speak to her, tell her I like her, but I need to see a male therapist. I mean between
you and me, I can’t say shit to her. I mean I can’t use words. I can’t say fuck, or
anything. Know what I mean?”
He told me who his therapist was, and I did, in fact speak to her. She agreed
that it was very difficult for him to relate to her, and said that he was quite formal
in the sessions and tried always to say the right thing. She thought that he would
be spending too much time trying to talk to her in a relaxed fashion, if he would
ever be able to at all. She mentioned that his attempt to use vocabulary that was
socially acceptable was actually endearing, but despite her efforts to reassure him
that it was all right to use the vernacular, he couldn’t do it. I became “Doubled-
Over’s” therapist.
He was a 37-year-old man who was friendly and very talkative. He had never
married, and as he put it: “I was the ‘Last of the Mohicans’ of my friends.”
Apparently, he was the only one of all of his friends who had not married and he
felt that most of his problems about women, and doubling over, were probably
somehow related to his loneliness.

“Yes man, I, am, lonely!” He emphasized each word separately, it seemed, to
reflect the emotional impact that he experienced about being lonely. “I even talk
to myself in the street, and sometimes I don’t realize that other people can hear
me until it’s too late. I know what that’s about. I’m lonely. No one to talk to.”
He regaled me with his history of ruminating on large breasts and indicated that
he started having these feelings sometime in his 20’s. He claimed to always have
been moved or aroused by any girl or woman with an ample bust-line. He stated
that it was more with women in clothes than it was when they were naked.
“Naked tits,” he said, “don’t get me wrong, I like them, but it’s better when she’s
in clothes. Like when I see the outline, and I can see that they’re packed in and
together, and that they’re a little heavy, you know, like they weigh something.” He
went on to explain that the breasts not only need to be large – they have to pro-
trude. He also said it was better when the woman was larger in stature rather than
slight or short. But he also explained that “better” meant also worse because when
it was at its best–when the woman was large in stature with large protruding
breasts–it was then that his doubled-over reaction, like being shot in the stomach
with a shotgun, would be the worst. So, he said, “best means worst, and worst
means best. How do you cure that?”
This man was one of three siblings. His brother and sister lived on the West
Coast and were only occasionally in touch with him. As he said, his friends were
all married or away, and he stated that his main task each week was to figure out
how to spend the weekend. He disliked going places alone because he felt a bit
shy, and he was not good at unearthing social or other kinds of events that he
might want to attend. Thus, each weekend became a drudge, and more often than
not, he would simply while away the time.
Monday mornings became his favorite time of the week because it meant he
could go to work, and the structure and requirements of his job would save him
from boredom. It was at his job that he interacted with colleagues, thereby satis-
fying a portion of his need to be social. He worked in the financial affairs depart-
ment of a large corporation and specialized in one facet of financial planning. He
stated that he was also formal at work, as he was with his female therapist. It was
only with his friends that he could let his hair down and relax.
To him, the main cue for feeling that he could be relaxed, was being in the pres-
ence of people with whom he could use profanity, colloquialisms, and all varieties
of sexual allusions. His early history growing up on the West Coast was one
within a lower socioeconomic context, and where his language was always pep-
pered with profanity (or perhaps more accurately, where his profanity was always
peppered with language).
“I tried thinking about the whole thing with psychology,” he said. “The best I
could come up with is that my loneliness is eating away at me, and that I really do
want to get married, so that when I see a beautiful woman the way I described, I
just feel it strongly in my stomach.”
In further describing his preoccupations, he confessed to ruminating about the
size of his penis which he referred to as his “dick.” He said it was amazing that
sometimes when looking at his penis in his bathroom mirror, it looked rather
large, and that that made him feel good, while at other times, it looked small, and
that he didn’t like. He wondered whether his mood had something to do with such
estimates, but reflected on the absurdity of it all; that is, how is a person’s penis,
measured in the flaccid state, or for that matter in any state, as both large and
small, or for that matter, both adequate and inadequate, or moreover, either large
enough or not large enough?
After he revealed his concern about his penis size, he also readily admitted to
not being able to discuss this with his female therapist. His interest in this subject
matter, and the amount of time he spent in this initial consultation talking about it,
suggested that he had gotten to the crux of his symptom, and that a great deal of
the therapy work, would have to be done, as it were, in his crotch.
He also described a recent scene in which he got drunk while at a dance because
as he put it: “I saw this great looking chick with big ones, and I just couldn’t go
over to her. I was stuck. No nerve. So I got drunk instead.” He indicated that the
next day when he was sober and contemplated his previous evening’s failure of
courage, it was then that he realized just how worried he really was.

It was virtually impossible to identify any specific who with whom this patient
was angry. There was no one person. Hence, almost by default, it became clear
that what was happening to him was that he was becoming angry at each and
every woman that affected him with his “shotgun in the stomach feeling.” For
one, that type of woman evoked an intense response in him, and second, despite
his urgent need to possess such a woman, he was at best, shy and at worst unable
to approach such a woman because of deeper psychological issues. Such a pre-
sumed deeper issue concerned strong inferiority feelings that subjectively con-
firmed for him his expectation that the woman would not respond to him
positively; he felt she would not be attracted to him.
Thus, apparently his wish was to possess such a woman. Yet, with respect to his
emotional life, the form in which the wish actually expressed itself was framed in
the context of his prediction that the woman’s most likely response would be an
unrequited one. In essence, it boiled down to his wanting her, but his feeling that
she would not want him.
His certainty that the woman, and not he, was the desired object, valued and
hoped for, made it virtually impossible for him to navigate the treacherous contours
of his dilemma. He could never feel equal to her. In contrast, he could only feel the
presence of his need, along with the dreadful anticipation that this need would go
unfulfilled. In view of this, it could be assumed that he was instantly angry at each
of these women because he anticipated not only that they would reject him, but in
his mind, that they had already rejected him even before any one of them ever laid
eyes on him. He was so certain of this rejection, that the future tense was not a real-
ity to him. The future tense morphed instantly into a past tense. It wasn’t that she
might not be attracted to him, it was that the verdict had already been made even
before anything happened. He was convinced that whoever the woman was, she
absolutely would not be interested in him even before anything happened.
Of course, since he would have felt instantly disempowered by this pre-rejec-
tion, it also can be assumed that the moment he spotted one of these women, he
also became instantly angry, and correspondingly, instantly repressed the anger.
Thus, he would never know he was angry. The only thing he knew was the over-
powering feeling of how his stomach felt.
His wish therefore, as it expressed itself, was an avoidant, indirect one. He
really wished that he not be rejected. This indirect form of the wish was derived
from his sense of inferiority or inadequacy so that the symptom itself, ending with
his doubled-over position, rather than alleviating discomfort, sustained and even
intensified it.
In a nutshell, and with respect to the symptom-code: (1) his wish was not to be
rejected; (2) the who was each large busted woman that evoked his shotgun-stom-
ach reaction; and, (3) his anger at her for what he felt was an axiomatic rejection
was instantly repressed.
Hence, his symptom of doubling over could be understood as the wish grati-
fied. This meant that doubling over whenever he spotted a large busted woman in
some way gratified his wish not to be rejected; that doubling over in pain meant
that he actually could possess the woman. The question is, why did doubling over
mean that? What did it mean that he needed to possess such a woman, but because
he felt he couldn’t, then he doubled over–wish gratified?

His two major themes in the session, as well as in subsequent sessions concerned
first, his symptom of doubling over and its relation to seeing women with large
protruding breasts, and second, a consistent focus on his penis size.
With respect to his focus on his penis, he easily revealed that from early on in
his life, he would have fantasies of possessing a large penis and that at first, when
he was an adolescent, in his fantasy he would exhibit it to girls and they would
admire it, and later when he was older, the same fantasy would be applied to
women, who also would admire it. Apparently, these fantasies were satisfying to
him, and even to the present, as stated, he would feel relieved when he perceived
his penis to be large.
Of course, his psychological understanding would ultimately need to include a
growing awareness of and perhaps a sense of the synthesis of three issues:
(1) How was his wish for companionship gratified by talking to himself? (2) How
was his wish to possess the woman with large breasts realized by his shotgun-
stomach and his doubling over? and (3) What was the meaning of his shifting per-
ception with regard to the size of his penis?
Of course, prevailing wisdom has it that breasts represent the nurturing wish.
Yet, in this case, his focus on breasts was not about his mother or the mother’s
breast, or mother’s milk, or mother’s presumed or even ostensible abandonment
of him. It seemed that the connection of the issues concerned the equation of
breast and penis. If he possessed the woman with large breasts, then he became
adequate because presumably, the large breast represented the large penis. In such
a case, whenever he created this equation, albeit unconsciously, he then would
feel adequate. Thus, under such a condition of possessing the woman with large
breasts, he would perceive his penis as large. This successful synthesis would
work for him whenever he fantasized that the woman with large breasts was
attracted to him. This would produce a feeling of pride in the size of her breasts.
Of course, he never realized that he was only equating breast with penis, thus cre-
ating a scenario in which he could essentially feel proud of the size of his penis.
This was a phallic obsession in which the defense mechanism of displacement
supported his repression, so that his focus was on her breast and not his penis. The
reality was that his steady-state, his normal state, was one in which he considered
his penis wanting in size. It was only when he fantasized the successful posses-
sion of the woman with large breasts that he was able to feel good about his
size–to feel adequate. In his case, he felt successful only in the fantasy, and
because of the repressed nature of the dynamic, he was never able to understand
his unconscious primary connection of breast and penis. When, on the other
hand he actually met a woman or saw a woman with large breasts, and because of
the reality of the situation, could not fantasize, then he would instantly experience
his shotgun-stomach symptom because he felt correspondingly instantly rejected
by her, even though she was in no way a party to this emotional and psychologi-
cal drama.
Another way of framing the conflict is to imagine that only in fantasy does he
successfully achieve his wish not be inadequate, that is to say, only in fantasy is
he able to achieve his wish to be adequate. In reality, his private noninteraction
with a woman he randomly encounters, produces a thwarting of his wish, so that
in his disempowerment, he becomes angry and represses the anger.
He becomes angry at the disempowerment because of not achieving the prize.
To him the prize seems to be to possess the woman with the large breasts.
However, the real prize for him is to feel he has a large penis. And when he is
feeling rejected by the woman with large breasts, he then cannot have the large
penis and ends up feeling his shotgun-stomach because when he can’t have her,
he’s not conscious that it’s his penis that is implicated. For him, consciously, it’s
just that his stomach hurts–a classic case of displacement upwards–in this case,
penis to stomach.
Thus, the therapeutic job here, contributing to the alleviation of the symptom,
in addition to surfacing the unconscious “facts,” would be to enable him to gain
additional self-esteem and begin to value himself, and not displace these concerns
onto his penis through a displacement onto large breasts.
It was the dominant force of self-doubt that needed here to be therapeutically
tackled. This would ultimately constitute the doing component of the symptom-
code ultimately escorting him out of behind The Line into an in front of The line
position.
Part III
The Clinical Casebook:
Inaccessible Symptoms
These are symptoms that are generally characterized by any combination of the
following factors, as being:
1. deeply engraved psychotic, or psychotic-like, and that have usurped the entire
personality;
2. chronically entrenched and/or somatized;
3. a function of an organic brain syndrome, genetic anomaly, or a particularly
thin ego;
4. a function of a catastrophic anger or rage implosion based upon an experience
of profound helplessness;
5. no longer an alien facet of the psyche but rather as having usurped the psyche.
With respect to the nature of the anger or rage implosion, such inaccessible
symptoms are so designated because the repressed anger:
1. is of the severest magnitude so as to have threatened almost all, or literally, all
aspects of the psyche;
2. is of such intensity that the psyche anticipates its imminent demise;
3. is of such sufficient depth that the psyche may anticipate a foreboding of being
imminently cleaved;
4. is so chronic that the psyche is likely to have already succumbed to the symptom.
Chapter 14
The Psychology of Blushing:
Involuntary Disclosure
of Success Wishes
In Part II of this volume, symptoms were presented that could be treated by

psychotherapy because they were not chronically entrenched. Nor, for the most
part, did they reflect a severe pathology. Further, such symptoms were not
chronically somatized or reflective of some organic condition or genetic anom-
aly; that is, they were of relatively recent onset. Rather than having engulfed the
personality, the symptoms remained as only a facet of the personality, one that
was retained in the personality, characteristically as an alien presence.
Thus, such symptoms could be directly approached via the symptom-code, in
which the wish, the anger, and the who, could often be identified. The symptom
then could be further isolated within the personality, and finally penetrated,
unraveled, and erased. This could be accomplished because the patient’s resist-
ance to understanding the symptom could be analyzed. Repression, therefore,
could be more directly dealt with, leading to a greater probability of the dissolu-
tion of the symptom through the undermining of resistance to change, and the
subsequent lifting of the repression.
In Part III, symptoms will be presented that resist psychotherapy treatment, and
therefore render the power of the symptom-code rather ineffective with respect to
cure, especially immediate cure. Thus, the inherent differences in treatment
between symptoms accessible to the symptom-code can be clearly distinguished
from those symptoms that are inaccessible and that resist the talking cure.
Blushing, is as an example of a symptom that resists cure; that is, a chronic
symptom that has been a characteristic psychological feature of the person’s
entire life. This kind of symptom can really only be challenged, but not usually
undermined, by the simple use of the symptom-code. This sort of symptom and
its embeddedness in the subject’s psychological context will need far more thera-
peutic work for it to be subdued. Even with such additional therapeutic work, cur-
ing such symptoms is frequently an unsuccessful hit or miss situation.
The explanation for this kind of resistance to cure, concerns the difference in
what it is that constitutes a symptom, and what it is that defines a trait. There are
symptoms which, because of their longevity, as well as how they have been knitted
into the fabric of personality, that become in psychoanalytic parlance, ego syn-
tonic. This means that the complement of personality traits that together comprise
91
92 14. The Psychology of Blushing
one’s personality profile, can contain certain characteristic symptoms that become
traitlike. For example, since all people are consistent in their behavior, then even
those who are unstable, unpredictable, or unglued, can be characterized by their
typical personality traits. “She is shy and will blush easily,” is a comment that
reflects a person’s typical behavior or attitude, and, when described this way, the
behavior is recognized by anyone who has known the person. “Yes, she is shy,”
would be the acknowledgment, “and further, we all know that she always blushes
when she is in (such and such) a situation.” Or, the symptom that is trait-like begins
to entirely characterize the person as a shorthand: “Oh, you mean blushing Sally?”
In other words, there are symptoms that become characteristic of the person
and are so entrenched and chronic within the amalgam of the person’s cluster of
traits, that for all intents and purposes, it is no longer meaningful to distinguish
that symptom from any of the person’s other traits.
From a psychological point of view, however, this homogenization of a symp-
tom into the class of phenomena identified as personality traits, is only descrip-
tive. From the clinical-scientific point of view, indeed, even though the symptom
is now also functioning as a trait, nevertheless, that symptom also remains a dif-
ferent species from that of traits. In this respect, the symptom of blushing, for
example, when characteristic of a person’s typical reaction to stimuli, conditions,
or circumstances, is truly a trait but also truly a symptom.
The difference between the trait of shyness and that of blushing concerns the
ability to voluntarily control the state. Usually, traits at least temporarily, can be
voluntarily controlled. The person cannot voluntarily and permanently eliminate
a so-called natural shyness, even though under certain more familiar circum-
stances, shyness can be less evident, or can be better controlled, or even that the
person is not at all shy under certain conditions of familiarity.
In contrast and with respect to blushing, the same phenomenological variation
is absent. The person always blushes in response to certain stimuli. Thus, there is
a psychology to the symptom of blushing, which in the original onset of the
symptom, is different from the psychology of the personality trait; namely, that
the blushing initially sits apart from traits. Yet, a blushing symptom can become
part of the person’s trait structure. When it does, it will retain its immunity to con-
scious decision making. Thus, the symptom is not subject to voluntary control,
and like all symptoms (and unlike all traits), and despite its presence in the
domain of traits, the symptom is both similar and different from a trait. In this
sense, the blushing symptom, like any symptom that insinuates itself into the
domain of traits, takes on the complexion of a trait–becoming part of the person-
ality profile–while also retaining its configuration, as a symptom.
The Symptom-Code and the Infrastructure of Blushing

Despite resistance to the symptom-code with respect to the talking cure, blushing,
as a symptom follows the same rules in its construction and formation as does any
symptom. Presumably, there was an original thwarted wish, and a consequent
A Case of Blushing in a 70-Year-Old Businessman 93
sense of personal disempowerment regarding this unfulfilled wish. This experi-

ence is followed by a reflexive angry feeling toward a particular person, a who,
the object of the angry feeling. If a sense of the impossibility of expressing the
anger directly to that who follows, then the anger will be repressed. Ultimately,
the wish emerges as the symptom, albeit in perverse or neurotic form.
In the case of the blushing symptom, its manifest or descriptive problem con-
cerns how the person feels about it. Usually, the subject of the blushing reports
feeling horrified at being noticed. The fear or apprehension of being noticed, and
therefore “sticking out,” bringing attention to the self (especially if that attention
to the self is in any way aggrandizing), is the worst fear. It is in such a circum-
stance that blushing appears. Of course, there are those who blush, but not during
conspicuous moments. These people seek attention, and yet under certain circum-
stances are plagued with blushing responses. Thus, although blushing usually
concerns the issue of conspicuousness, there are other circumstances that can also
call forth the blushing response.
With respect to the psychology of blushing therefore, usually, but not always,
the person’s worst fear is to be noticed. This issue of being noticed can take many
forms. For example, winning an argument or calling attention to oneself in direct
or even in inadvertent ways, qualify as pivotal stimuli to the blushing response.
The manifest level to the blushing phenomenon, therefore, consists of a dread,
apprehension, or fear of standing out. Yet what happens is that the person’s worst
fear is realized. In contrast to not wanting to stand out, the person’s face turns
crimson, or darker, which paradoxically, makes the person really stand out. The
person, the subject, can feel the blush, and further, feels existentially embar-
rassed, even horrified, thinking that others are also seeing it.
A Case of Blushing in a 70-Year-Old Businessman

“You saw me almost blushing, didn’t you.” That was what this patient asked me
after he mentioned that he became quite wealthy when he finally sold his stock in
the pharmaceutical company he founded. Even he, a 70-year-old man, needed to
hurry, to rush past the moment when he felt himself blushing. He began talking
about other facets of his business in order, with great effort, to blunt what he expe-
rienced as this personally embarrassing blushing characteristic. But he stopped in
the middle of this new story to ask me the question about my noticing his “almost
blushing.”
Thus, he would not even acknowledge to himself that he blushed nor that it was
evident to those who were looking at him. Apparently, he had convinced himself
that he was able to morph the blushing moment into a segue that he felt averted
the obvious and visible evidence of his blushing. Yet, his notion of an “almost
blushing” incident was not at all valid. Despite his illusion that he could avoid
blushing, it was plainly not true. In this man’s case, the blushing was not crimson
red. He was a dark complected man and his blushing appeared as a slightly darker
skin tone.
He acknowledged having had this problem all of his life and feeling uncom-
fortable about it since he first began experiencing it in grammar school more than
60 years earlier. He had discussed it in two therapy experiences but reported no
success whatever in overcoming it.

This man’s symptom was integral in his personality, and not merely an aspect of
it. As pointed out in the preface of this book, his symptom qualified as one of
those that are unlikely to respond to the powers of the symptom-code. His was a
symptom that had integrated itself into the amalgam of traits that composed his
characteristic personality profile. As such, his blushing impulse had attached
itself to the entire underlying circuitry of his personality, and was not encapsu-
lated as a separate entity, outside of the main template of his personality.
Nevertheless, although curing him of his blushing would be a difficult task, it
would still be possible to apply the symptom-code, in order to understand what
the symptom meant. First, it was necessary to define his basic wish. Next, it
needed to be understood that his presumed lifelong repressed anger had become
knitted into his personality – habituated. Third, it needed to be assumed that there
was an original who, who in his more than 60-year past, was associated with this
repressed anger.
In questioning him, it became evident that in his childhood home, a pious home,
pride, as a value, was strongly discouraged, even perhaps, prohibited. Thus, this
man was always taught to minimize any personal achievement. Apparently, it was
the ethos of the home that only modesty would be valued. Boasting especially was
prohibited and even considered to be sinful. The wish for recognition, therefore,
was necessarily relegated to his solipsistic unconscious–the only place it could
reside. Thus, whenever something he said approached a discernible assertion of
pleasure or pride in his aspirations, accomplishments, or achievements, involuntar-
ily, he would blush.
The point is that his wish had been translated into the symptom, albeit it in a
perverse form. In this person’s case, this translated symptom also occurred
because in order for a rather normal expression of pride to occupy some place in
his overall repertoire of responses, ironically it surfaced as blushing. Of course
the paradoxical, oxymoronic, and fascinating fact here is that in not wanting to
face any feelings of pride that he may have harbored, his face showed that his
underlying, unconscious, true feeling, was prideful.
The point here also implies that even with respect to unconscious forces, he
could not express pride in anything he had accomplished. But because he could-
n’t have his wish, because the wish to express pride was thwarted, then according
to the symptom-code, it is proposed that he became instantly angry. His anger
thus would have been related to the prohibition against expressing himself nor-
mally, in this case, feeling consciously proud of his achievements. The thwarted
wish, however, would give him the opposite sense, of weakness, helplessness,
A Case of Blushing in a 40-Year-Old Librarian 95
disempowerment. The anger would have been his way of momentarily empower-
ing himself. Of course, the problem was that he could not, or would not show this
anger, whether or not he was conscious of it, for fear of revealing his original,
concealed pridefulness.
The anger, by definition, became repressed because he had a very definite symp-
tom. It could be assumed therefore, that it was his father (whom he indicated was
the disciplinarian and decorum-governor of the home, the one who set the rules
about comportment), who was the who at whom, as a child, this man was angry.
The psychoanalytic implication is that he would need to be conscious of his
unconscious anger toward his father, and to examine and work on it, to make it
conscious, and then to do something that relates to the original prohibition
against owning his personal achievements. It is proposed that until that happened
the symptom would be sustained as part of his personality-trait system, and not
as a separate part of his personality, specifically as a compartmentalized, alien
symptom-characteristic.
In his present state of knowing, what happened was that whenever he reached a
point in conversation with others in which his accomplishments and achievements
appeared, especially in bold relief, then he became angry, because he couldn’t
show his pride, and then at once repressed the anger. His blushing appeared, which
represented his true underlying wish to be noticed, a wish gratified, albeit in this
translated, perverse form. This presumed original wish to be seen, was now there-
fore realized. Getting red in the face, gets you seen-ultimately, an involuntary dis-
closure of success–wish gratified.
A Case of Blushing in a 40-Year-Old Librarian

This woman was a cooperative person who, like the patient in the clinical illustra-
tion above, was also quite concerned with propriety, and was modest to a fault.
She indicated that her career as a librarian was suitable for her. She was the
youngest of five sisters and was happy to be one of them. She indicated that they
were all quite supportive of one another and considered one another to be each
other’s closest ally.
The patient’s two main personality problems were that first, she claimed to be,
and was in fact, extremely deferent in her behavior toward others. She would be
the one to always permit others the right-of-way, and generally she felt awkward
about interactions in which her contribution was seen as effective, intelligent, or
valuable. In clinical terms, it was difficult for her to assert her everyday normal
entitlements without feeling, as she said, “too forward or too egotistical.” Second,
she would never assert any sort of pride in what she did, and in a profoundly min-
imizing stance, would feel better, as she stated, “losing rather than winning.”
She also always felt uncomfortable whenever she was praised. Under such cir-
cumstances she would involuntarily blush a bright red. She was a fair skinned
woman so that her blushing was red hot, and correspondingly, she always
felt exceedingly embarrassed by it. She was never able to cure it, and had been
suffering with this malady, this symptom, all of her life: “As long as I can remem-
ber,” she said.

This woman was the sister in her sibling group who was most interested in main-
taining harmonious family relationships. As the youngest in the family and “since
early on,” she said she had always felt secure as one of the five. She was grateful
that her sisters accommodated her, and she was always the one to do sacrificial
things for them.
In investigating her sibling relationships further, it became clear that she was
always acutely aware of never besting her sisters, and hated any competitive
games in which she participated. She always had a bad feeling about winning
anything when it was one of her sisters at the losing end, and she claimed that
often she would deliberately “not play well so as not to win.” Whenever she won,
she would automatically blush, and was petrified each time that occurred, know-
ing full well that the blushing was imminent and that there was nothing she could
do to prevent it.
Thus, as in the previous case, this woman never permitted herself to express or
demonstrate anything concerning pride. She felt that to express pride would mean
that she was better than her sisters, and on her part, this was always a conscious,
yet horrible thought.
Applying the symptom-code to this case revealed possible avenues leading
to the meaning of her blushing symptom. First, her basic wish and the impos-
sibility she felt of realizing it, is possibly an easy one to understand. It seemed
that her protestations of doing anything in the world but win, revealed the
opposite predilection–namely that she would desperately want to win, but by
no means did she feel emotionally or psychologically equipped to do so.
Apparently, her greatest fear was in possibly losing the affection and support
of her sisters. The thwarted wish presumably created feelings of disempower-
ment as well as angry feelings, which she could never acknowledge. In this
respect, the anger, because it could not be directly expressed to its intended
who (a sister perhaps), necessarily needed to be repressed. The wish was then
translated into the symptom of blushing. In her attempt to avoid being seen, by
winning, for example, the symptom of blushing created the circumstance in
which her basic wish was realized, albeit in perverse form-when she blushed,
she was seen, and vividly so.
It was assumed, therefore, that her truest unconscious wish was to be the win-
ner. And if by chance she won, or came close to winning, she always ended up
blushing. The blushing also necessarily meant that she was angry at someone. In
this case, the someone, the who, would have been one of her sisters or some other
transferential sister-equivalent. In this sense, it could be hypothesized that her
competitive strivings were adumbrated by any particular sister-figure against
whom she needed to be less than successful.
A Case of Blushing in a 28-Year-Old Physician 97
It could easily be further hypothesized that this woman’s blushing reflected an

involuntary disclosure of success wishes. It could be assumed that she always
wanted to be proud of her talents and accomplishments, and wanted to display her
successes, to take pride in them, feel joyous about them. Yet, her belief may have
been that should she express her success, unencumbered with apprehension, then
some dire happening could result and her relationship with the who could possi-
bly be forever contaminated. It further seemed that the prohibition against ever
feeling proud of herself, or especially of expressing such pride, was what her
blushing symptom was really all about. She had no sense of entitlement because
to assert her needs as a first among equals would have been tantamount to perma-
nently damaging the relationship between her and her sister or sister-figure, the
presumed who.
Thus, this woman needed to remain in the background, with no real entitlements,
no ability to feel normal about competitive games of any kind, and no insight into
how terrified she must have been at her own repressed anger or rage. It is quite
likely that the anger about her massively repressed state was too much for her to
manage. Her particular personality pattern was such that she would continually
reject any more publicly visible position for a more inconspicuous one. Of course,
whenever she said or did the slightest thing that seemed smart or valuable, in any
way that was noticeable, she would instantly blush. It was the blushing, however, of
someone with an unconscious impulse that involuntarily disclosed the presence
of success wishes.
A Case of Blushing in a 28-Year-Old Physician

“It would always happen in class,” he said. “All my life, wherever I was in school,
even in medical school, it would happen. The damned blushing.”
This was a man who, to begin with, had a fair complexion with rosy cheeks. He
was physically conspicuous because of his girth and height. He was a large
person, who, despite his blushing symptom, nevertheless was gregarious and
actually sought the spotlight. In his case, the blushing would occur if in any dis-
cussion, he made a mistake about some fact, or if someone proved him wrong. It
was under such conditions that he would feel wounded, and as a consequence,
would blush. Other than being wrong or getting some facts jumbled, or doing
something awkwardly, he would not blush. Instead, and with relish, he could win
contests and be the center of attention. Thus, the blushing symptom in this man
was quite different from the blushing symptom for each of the other previous case
examples discussed, even though there exist thematic strands that tie together the
blushing symptoms of all three cases.
This man was a cultivated, highly intelligent, well educated, and erudite
person. He took much pride in his profession and was careful to comport himself
as he understood it necessary for a physician to do. His intellectual style was
aggressive and he had a wonderful and easy command of language. Along with
this, he was merciless toward others who he felt were not equal to whatever the
intellectual task was that they had assumed. In such cases he would confront the
person in a way that could be embarrassing to that person. This, despite the fact
that if the situation were reversed, and he was the one challenged, his embarrass-
ment, especially if he knew he was wrong, would be great, and without a doubt
would cause him to blush a bright red, from the base of his neck to the dome of
his bald skull. Nevertheless, he showed no empathy to others and could force
others into these embarrassing intellectual encounters.

In this man’s case, the wish that was presumably thwarted could be defined as
one, that in a strange way, recapitulated his growing-up experiences. The who, it
seemed was his father, who would constantly test him on all sorts of information
regarding a wide array of subject matter. As a child, his pleasure was in getting
the answer right. The problem was that his father would increase the complexity
of the questions so that each and every episode of these question and answer peri-
ods would end with this man not knowing something. Then he would feel that his
wish to be accepted and loved by his father was interfered with in the face of the
father’s distinct disapproval, or even sarcasm, regarding either the son’s wrong
answer or inability to answer altogether. Thus, in effect, each of these episodes
was designed by his father to begin with success and end in failure. The objective
then, in this “game,” was to get his son to fail, to be disappointed. This kind of tor-
ment had continued all through this man’s formative years.
The suggestion that this sort of template underpinned all of his blushing expe-
riences was reasonably supported by his observation that he always blushed when
finally he didn’t get the answer. “I always noticed it when I couldn’t answer or
when I got the wrong answer. Then I would blush.”
In this particular case, there was little doubt that his father was the who toward
whom he was angry. After the anger was repressed, his blushing then possibly
became the perverse expression of his wish to be noticed, to be the winner, to be
loved. And even to the present time, and despite his professional stature, his
blushing seems to be an involuntary disclosure of success wishes.
The application of the symptom-code presented here, would, in all likelihood,
not have the power to erase such a blushing symptom because of how this symp-
tom, over many years, became organized in the personality; that is, because of
the symptom’s chronicity it had become embedded in this man’s personality trait
structure, and was no longer an encapsulated product of his psyche. On the level
of trait then, the blushing symptom was no different from his aggressive trait of
intellectually challenging others as his father had done to him. Yet, the key to his
blushing concerned his strident yearning for success, as though he had never
resolved the need for his father’s complete, unconditional approval, and in a
manner in which the end result of any interaction, would be a winning and not a
losing strategy.
Commonalities of the Cases 99
Commonalities of the Cases

In all three cases, the vectors of these respective wishes, was to avoid something.
In all three cases, the indirect, avoided “something” (wish) reflected variations on
the theme of the management of success and failure. Therefore, because these
wishes were indirect, then the symptom itself was painful. And indeed, in all
three cases, blushing itself was extremely embarrassing and more or less painful
to each of the subjects.
Furthermore, because of the resistive, chronic nature of these blushing
symptoms–as samples of personality trait structure, and no longer merely as
solely encapsulated symptoms that exist apart from the domain of personality
trait structure–these patients, it was predicted, would find it more difficult to
cure the symptom by resolving the conundrum of symptom as trait. This
conundrum consists of prying loose the symptom from the domain of traits,
and transporting it to the region of the psyche reserved for products alien to the
personality, in this case to the domain of wishes and symptoms. Then with
respect to the blushing symptom itself, it is a symptom-condition in a behind
The Line state needing much work in order for it to shift to a more in front of
The Line position signifying its readiness to be successfully treated with the
symptom-code.
Chapter 15
“No Writing!”: A Case
of Delusional Self-Incrimination
In this case, the particular inaccessible symptom that will be described was a
highly visible, encapsulated one, embedded within an unusual delusional system.
The symptom was so entrenched and so delusional that in examining the case, it
became difficult not to be struck with the notion that what we were looking at was
the anatomy of a psychosis. Yet, it was a psychosis without hallucinations, gen-
eral distortions, word salads, tangential thinking, flat affect, incoherence, or any
other conventional criterion used to diagnosis psychosis. The psychosis was, in
derivative form, exclusively reflected in the delusion, which was a distortion, but
highly specific, one that did not contaminate other aspects of the subject’s cogni-
tive organization. What it did do, however, was contaminate the subject’s primary
relationship–it contaminated his partner’s ability to be with him, because to live
with such a specific distortion in a partner, and to hear about it incessantly, would
be too much for any normal, balanced person.
The patient was a man in his 50’s who was a crackerjack salesperson in the
men’s department store of a well-known clothing shop. He was the single most
productive salesperson despite a tremendous handicap in the administration of his
job. All of his coworkers knew about his idiosyncrasy (what they called “crazy”),
and unfortunately, all took advantage of it.
The symptom was one in which the patient could do everything required of him
as a salesperson except commit anything to writing. “No writing,” he would say.
He could not bring himself to write, and therefore, would not write. He was natu-
rally intelligent, even gifted, and despite only a high-school education, was an
avid reader, was quite literate and in fact, wrote well. Yet, under no circumstance
would he put anything in writing.
Now, of course, this was difficult for him because he needed to write sales
slips. His solution was to get various other salespeople to do it for him. The catch
was that these other salespeople charged him a percentage of the sale to write the
slip. In street parlance this is known as, “paying the vig.” Since he was extremely
productive as a salesman, then the “vig” each week was considerable, so because
of this problem approximately 15% of his income went to the other sales people.
No matter what his wife said or how she implored him to write the slips himself,
his consistent mantra was: “No writing!”
101
102 15. “No Writing!”: A Case of Delusional Self-Incrimination
This case is an example of the distinction that needs to be made between a symp-
tom that is entirely isolated in the personality versus one that infiltrates the personal-
ity so that rather than only being an aspect of the personality, the symptom becomes
the personality. In this case, despite the fact that the symptom remained encapsu-
lated, nevertheless, it also influenced his entire personality. Despite the fact that he
could function in all other ways, nevertheless, his symptom was so pervasive within
his work life, and so intrusive with respect to the space it occupied in his marriage,
that the symptom itself began to characterize his personality. The symptom there-
fore, became his most visible, dominant trait-characteristic. People who worked with
him would laugh at him as though his problem was all there was to him.
Since this symptom had been plaguing him for the past 30 years, then naturally
he had not written sales slips for that 30-year period, so that the possibility that
his symptom could easily be cured through psychotherapy and by the application
of the symptom-code, was rather unlikely.
The question became one of attempting to identify his basic wish, identify his
repressed anger, and identify the who with whom he was presumably angry.
Because this was such a chronic, long-standing symptom, it was also evident that
the original who, also had surrogates in this patient’s everyday life. Thus, with
respect to the talking cure, and because of the encapsulated psychotic nature of
his delusional symptom, the problem here was clearly that of an inaccessible
symptom. When the details of his reason for not writing such sales slips were
uncovered, then the encapsulated psychosis, as portrayed vividly in his delusion,
was revealed. He was now also depressed because his wife had left him, and med-
ication along with psychotherapy was seen as the best course of treatment.
The Delusion
This patient’s wish became understandable after he admitted that he would not
write sales slips because he felt whatever he wrote would implicate him in some
crime. He also admitted to feeling uncomfortable whenever he read in the daily
newspaper or saw on television news of some terrible crime. His discomfort in
reading or hearing such news was such that he felt vulnerable, and believed he
would be apprehended by the police for the commission of the crime. Thus, it
may be possibly conceived that his fear about writing anything concerned an
imaginary impulse that he anticipated, that might jump out of him and incrimi-
nate him in whatever crime or wrongdoing was reported in the news.
The main problem for him was the distinction between what he knew and what
he felt. What he knew is that he really didn’t commit any crime at all. Yet, he was
gripped by an obsessive, all consuming feeling that, in fact, he did do something
wrong, and that this wrongness would be revealed should he write anything at all.
Thus, for him, “knowing” had very little power, while “feeling” was compelling.
It was a case of a “knowing” that was obsessively gnawing at him, and a “feeling”
that was paranoid. In one person – the obsessive versus the paranoid – the para-
noid was always victorious.
Thus, simply stated, he was basically afraid that if he wrote anything down in
black and white, he would not be able to control his impulse to confess, so that
what he wrote would turn out to be his confession. He was guilt ridden and this
feeling permeated his very being.
In a deeper sense, with respect to his basic self-image and ego, at the core of his
personality it certainly could be assumed that he felt himself to be completely
imperfect, incomplete, inadequate, and inferior, and was most likely furious
about this self-assumed inferiority. Thus, this delusional thinking regarding his
self-incrimination was a direct reflection of a psychosis. The delusion was all-
consuming and he continually acted it out.
Because the entire syndrome was so chronic and so pervasive, the thought of
succeeding with this patient in a psychotherapeutic endeavor in the absence of
medication would in all likelihood have been folly. It is an example of attempting
to understand and treat an ambulatory character psychosis in only partial lifelong
remission. The remission was partial because, he retained the delusional thought.
Yet, in all other spheres of his life, he was in tact.

The patient supplied only an outline, a sketch of his history, but enough to begin
to speculate, however tentatively, about the underpinnings of his symptomatol-
ogy, despite the fact that his memories of childhood were sparse, and therefore, it
was difficult to pin down specifics.
The patient was an only child and his parents were disciplinarians. He indi-
cated that there was not much affection in the home and the memories that
remained with him mostly concerned what he thought was his mother’s inatten-
tiveness and punitive style, and what he thought was his father’s sarcasm. For
example, he remembered that he felt he could never get what he wanted. He was
not sure that was quite the case, but he said it always felt that way.
Whatever the truth, it seemed that his dominant feeling toward his parents
was, in the most general sense, quite negative, and in the more specific sense,
may have been and continued to be, a very angry one. This speculation was sup-
ported by his memory that he thought they were once almost killed by a truck in
a traffic mishap. He was a young teenager at that time, and he had the thought
that if they indeed were killed, he would be free and could do the things he
wanted to do. But he wasn’t sure about the memory. He seemed to also remem-
ber feeling guilty (and it can possibly be assumed, ashamed about such a
thought), and confessed that, “To this day I still think about it and I think maybe
if that’s what I thought that then I wanted them dead. I try to put it out of my
mind, but sometimes I can’t.”
He only had vague memories of his father, describing his father as a nonpres-
ence. He also reported not even having a clear memory of his mother. The frag-
mentary, yet detailed reportage of his relationship with his father was of a
“drinking man who never talked, and mostly did what my mother wanted.” The
104 15. “No Writing!”: A Case of Delusional Self-Incrimination
patient could not recall a single instance in which his father gave him something
he asked for or countermanded his mother’s refusals.
The speculation that might be made from this rather sketchy history of his early
life, concerns how the symptom-code might be applied to an understanding of his
symptom structure. In this case, identifying the who was difficult. Was it his
mother or father? He was only somewhat aware of the negative feelings toward
each of them. However, even though he was vaguely aware of his dissatisfaction
toward his parents, it is probably safe to assume that it was really anger or rage
toward them that remained unconscious.
It is proposed that his repressed anger was directed toward a specific who,
mother or father. Part of the problem was his inability to produce clear portraits of
his parents, or for that matter, of any other possibly important figures of his form-
ative years.
The wish, is probably not difficult to guess. Since it would seem that his guilt
reveals some basic rage against each of his parents – a guess based mostly on his
obsessive, intrusive memory of thinking it would have been good had they been
killed by the truck – then the rage he presumably felt, and continued to feel into
adulthood, can translate from a wish that it would have been good had they been
killed by the truck, into his wish to kill one or the other himself. It seems likely
that his thought that he wanted the truck to do it, may already have been a transla-
tion of his chronic rage toward them, so that the truck was really a substitute
object representing his own primary wish.
This rage was likely the equivalent of a wish to kill. Usually people can have
such wishes, but they are harmless and remain on the level of wish, fantasy, and
even on the manifest level of figure of speech. In this patient’s case, perhaps the
original wish developed, as suggested above, as a chronic and intense one, and it
may be that he didn’t have the resilience to see it as different from behavior. In his
behind The Line withdrawal and fantasizing, thinking became equivalent to
doing. Thus, he felt guilty that he had committed a crime – one of the ultimate
crimes. It can be speculated that the distorted dynamics of his psyche began to
govern and even dominate his personality, and even though he knew he didn’t do
it, nevertheless, his feeling that he did do it may have prevailed and triumphed
over what he actually knew. It could have been that in the organization and
tyranny of his psyche, as stated, knowing had very little power, while feeling was
compelling.
Thus, as a strategy, not writing made sense. It meant that because uncon-
sciously he had convicted himself of murder, then not writing kept him both in a
guilt-free state, and at the same time enabled him to avoid the legal procedure for
the crime, and, in addition, to avoid incarceration or worse. He could also be
guilt-free because in the acting-out of the symptom of not-writing, the meaning of
the symptom could remain unconscious; that is, because he acts out the symptom,
then he doesn’t have to know that he killed either his mother or father, which
unconsciously, he, of course, in all likelihood, believed he had done.
This definition of acting out as described earlier, is the classic psychoanalytic
definition; that is, that acting out is an attempt to do something rather than know
something. In this patient’s case, the doing presumably was expressed by enact-
ing the symptom, and the not-knowing concerned his imagined self incrimination
in a parent’s ostensible murder.
With respect to the symptom-code then, the hypotheses here include: that his
wish was to be free; repressed anger was identified; and, the who, of course, was
hypothesized to be one of his parents, presumably toward whom the original rage
was directed. Finally, it should be remembered, as reported in Part I, of this book,
that a direct wish produces a symptom that relieves tension, while an avoidant
wish is defined as indirect, and produces a symptom that sustains or increases ten-
sion. In this patient’s case, his wish was a direct positive one –to do something
rather than avoid something. The “to do something” was the wish to be free.
Symbolically, whenever his symptom of not writing was acted out, it meant he
was free because the culprit parent was dead – murdered by him – and further, the
memory of the murder therefore kept unconscious. Hence there was a relief of
tension each time he didn’t write.
Of course, this entrenched symptom, which at all costs and with respect to his
delusion, apparently needed to be protected, reinforced, and fortified, kept him
behind The Line in an insular obsessive/paranoid withdrawal – albeit encapsulated –
and made it impossible for him to be front of The Line, in a reality position.
The postscript here is that his father died of throat cancer ten years earlier when
the patient was in his mid-40’s; his mother, still quite extant, and in her late-70’s.
Chapter 16
“I’m not Going to Work Today”:
A Case of Agoraphobia
“I’m not going to work today.” That quote was the first crystallized conscious hint
of the problem in a 60-year-old woman who for the past 20 years, had worked as
a bookkeeper for the same firm. She had never married, and despite her modest
income, owned her own luxurious condominium apartment in a large metropoli-
tan area. In addition, she owned an expensive luxury automobile, and her closets
were literally jammed with the latest and most expensive tailor-made clothing.
She vacationed twice a year for a month at a time. She never cooked for herself,
and dined in expensive restaurants. All of this considered, her only visible source
of income was that from her job as bookkeeper.
Her problem began with her initial statement, “I’m not going to work today,”
that she made to herself, out loud, and ended with her repeating out loud: “As a
matter of fact, I’m not going to work, period.”
This is how she reported the revelation that she was feeling different. In this
case of a woman with severe agoraphobia, it could be predicted, as in the previous
chapter of a case of delusion, that psychotherapy treatment would not be the effi-
cacious sole strategy of choice. In the previous chapter, the therapy alone would
have been impossible because of the chronic, entrenched nature of the problem,
and because the symptom was encapsulated as a psychotic delusion, and further
because the patient’s memory of past people and events was quite vague. This
made it difficult to capture the memory of the specific who with whom he had
been angry.
Similarly, with the present case, psychotherapy alone could not solve the prob-
lem or cure the symptom, because a severe, even cataclysmic implosion of rage
was assumed to be the cause. Moreover, this implosion is assumed to have been
so devastating, that the anger-debris was, most likely scattered throughout her
psyche. It would be impossible, therefore, to collect the anger and reconstitute it
into the original rage reaction; that is, to reconstitute the memory of the who as it
is connected to the rage. An effective therapy without medication was thus pre-
cluded. And this conclusion seemed valid, even in the face of her very conscious
identification of the who.
Along with a medication regimen, a psychotherapeutic process was undertaken
with this woman in a quest to stem the tide of the accelerating agoraphobia. The
107
108 16. “I’m not Going to Work Today”: A Case of Agoraphobia
point was that she was deteriorating, the agoraphobia was accelerating, and she
was set on the worst possible pathological course. By the time the patient began
treatment, she was unable to be away from her apartment. As fortune would have
it, she was able to visit a therapist whose office was at a separate entrance to the
building in which she lived. However, these visits required her to leave the build-
ing, walk four or five steps to this other door, and yet, even this was only possible
for a while. Despite the medication and therapy sessions, after only some ses-
sions, the agoraphobia became resistant to any sort of intervention.
In short order, not only would she not go to work, but she would not leave the
lobby of her apartment building. Soon thereafter, she could not leave her apart-
ment. Still later, she had decided she would not leave her bedroom, and then, of
course, her perimeter was reduced to the circumference around her bed so that
then her bed itself became her universe. This sort of extreme agoraphobic symp-
tom is not unlike that of Howard Hughes, the billionaire who eventually would
not or could not leave his bed.
Although knowing the symptom-code and feeling certain that applying it could
produce some insight, for sure, it’s use could not cure this hugely dense symptom.
The symptom itself was profoundly resistive to treatment and her hypothesized
implosion of anger so very severe, that she was entirely and hopelessly infused
with rage. The story she initially told, which she herself described as the problem,
seemed indeed to be the problem.
Apparently, for the past 20 years, the duration of her employ, this woman had
been having an affair with her very wealthy employer. When she first started
working for this man she was about 40 years of age, and this was to be the first
long-term relationship of her life. She reported having had several boyfriends, but
all these past relationships were of short duration.
Her history implied that she was a very dependent person, having lived with a
bachelor brother for the 10 year period prior to her bookkeeping job. At that time
she had no real savings and lived month to month, spending all of her earnings for
rent and other necessities. When the affair began, this man who was married with
a family of his own, was 60 years old. Before the end of the first year of their liai-
son he purchased an apartment for her and there had her safely ensconced for the
ensuing duration of their 20 year relationship. In addition, he continuously show-
ered her with expensive clothing and jewelry, and as a bonus, generous cash gifts.
Over the ensuing two decades, she invested much of that money and became
affluent on her own.
Because he was so considerate as well as generous with her, she never believed
he would terminate their relationship. Rather, it seemed that because she became
financially independent, it would be she who could step away from the relation-
ship. As it turned out, and in a psychological sense, she would never have been
able to leave the relationship because she was so emotionally dependent on this
man. She believed that the same need she had for him, he had for her. To whatever
extent that may or may not have been true, eventually, and immediately preceding
the point of the acute onset of her agoraphobic symptom, he had broken their tie.
At first, after he turned 80, he began to complain that rather than his schedule
easing, it was becoming tighter, busier. Then he suddenly announced that he
would be unable to see her as much. It was then that she started spending week-
day evenings as well as weekends, alone. This was in contrast to how it had
always been with them. In the past, for them to spend one weekend day and one
or two evenings per week together, had become a tradition and this had continued
throughout their relationship.
In addition, her bonuses stopped and he informed her that her job would be
reduced to two days a week. Decreasing her visibility at the office was the partic-
ular stimulus that crystallized her anger, – making it palpable. The other insults
made her feel “bad, upset, disappointed, sad,” but not consciously angry. Of
course, these adjectives she used were all code words for anger, but she was not
able to experience the anger. At first, she could only experience feeling “bad,
upset, disappointed, and sad.” Then she began to realize she was angry at him. All
along, however, and unconsciously, she was most likely, raging against him. Yet
she could not permit herself to be conscious of this rage because its very magni-
tude would indicate to her that their relationship was really, in effect, no more.
The point about her minimal presence at the office felt to her as though he was
going to incrementally decrease her presence to zero. This seemingly inexorable
advance to zero was difficult for her to bear because, as she put it, “My only claim
to fame was that everyone at the office knew I was important.” Apparently, all the
employees knew that she was the boss’ “special friend,” and so they all deferred
to her, and for those two decades she was treated like royalty. This was the only
period of her life that she felt special, despite the fact that she was special only
insofar as she was illegitimate royalty. Her employer never intended to leave his
wife and family and always told her so. She accepted the arrangement because as
she herself said, “I knew I was never going to be married, and I never wanted to
have children, so this was just perfect for me, and I loved him.”

In this case, application of the symptom-code was quite simple. Her wish was a
direct one, she wanted him to stay with her – a positive wish. Ultimately then, an
increase in tension was experienced if there was any demand for her to leave her
apartment, which for her could only mean that she would have to be in an envi-
ronment, that in reality implied her “demise.” The only cure for this increased
tension was in the agoraphobic symptom; that is, gratification was gained if she
did not leave the apartment. Her tension would be relieved if she obeyed the ago-
raphobic mandate; remaining “closeted” therefore, was an absolute denial of
what she felt was her horrible reality.
Second, as stated, it is assumed that she swallowed an enormous amount of rage
and didn’t know it except that she had a hint of this repressed rage when finally she
learned that her job had been cut back. In this respect her humiliation was too
conscious and she could not avoid recognizing it. Otherwise, as she indicated, she
110 16. “I’m not Going to Work Today”: A Case of Agoraphobia
felt bad and sad and disappointed, anything but furious, and enraged. Thus, this
woman used an entire glossary of anger synonyms or code words for anger rather
than being conscious of her debilitating, volcanic inner devastation. Certainly, this
kind of utter rejection assumes the presence of a maximum amount of repressed rage.
Third, the who, with whom she was enraged, was obviously her boss/lover.
Knowing it did not at all have any salubrious effect on her. The fact was that her
emotional dependency on this man was all-consuming. She herself could never
have left him, and she knew that he was aware of this. In addition, it was he, who
terminated the relationship in the abrupt, impersonal manner that she reported,
and this was enough evidence to reveal quite a plausible rationale for her pro-
found sense of diminishment. The result of it all was the appearance of a terrible
symptom that was inaccessible to treatment.
It was a death. In a case with such intense dependency, the abrupt cessation of
the dependent relationship could easily produce the kind of powerlessness, the
kind of helplessness that generates intense rage, that in this case was initially
managed by keeping the intense feelings unconscious, out of awareness. Thus,
the agoraphobic symptom resulting in this woman’s confinement to the perimeter
around her bed was equivalent to her death. She could not function without the
dependent relationship. She was not alive without it, and for all intents and pur-
poses, she was essentially acting out her death. The acting out, the agoraphobic
symptom, was so acutely entrenched that it would seem that only one key could
unlock it, and that key was not the symptom-code nor perhaps was it even the
medication. The only key that would seem able to unlock the symptom was a
reconstituted and secure dependent relationship.
Thus, if her lover would suddenly appear at her bed, and tell her that it was all
a mistake, that the relationship would continue to be how it always was, and that
most importantly, she could, of course, return to her job full-time, then it is
assumed that her sense of self-esteem would instantly return and like magic, she
would surely recover her bearings; especially with the realization that her royal
privileges still obtained. Only then, would she permit herself to be cured and only
then would she be able to cross The Line into a doing reality place and out of her
deadly withdrawal. It was not to be.
Chapter 17
Chaos: A Case of Compulsive
Collecting and Hoarding
A 55-year-old man had been collecting disability insurance since his accident in a
machine shop some years earlier. He had slipped on an oil spill and eventually
needed back surgery. He never again had a salaried job. However, he was exceed-
ingly happy with his avocation. He fancied himself a master craftsman.
He lived with his wife and 15 year old daughter in a house that his wife had pur-
chased with inherited funds. His wife and daughter were attentive to him.
However, they were really pitying him and trying to shore him up, to reassure him,
to strengthen his ego. The real problem they faced was that he was a collector and
hoarder. Further, although he knew how to build things, he was never able to finish
a project, and so there were half-chairs, and half-cabinets, and so forth, strewn all
over the house. The problem was so severe that the daughter could never have
friends over because the scene was quite bizarre.
This was the case of an obsessive-compulsive disorder, with an emphasis on
the compulsion, almost certainly masking deeper pathology. His penchant for
amassing clutter was based on his notion that whatever tool or stray piece of
wood he would come across, could possibly be useful to him in his work. Thus,
over more than a decade, the house was loaded with junk. Apparently, not a sin-
gle surface was available on which even to place a saucer.
His wife was at her wits end, and threatened to leave him unless he sought
treatment. She reasoned with him, trying to appeal to logic, saying to him that of
course he knew that he never finished making even a single piece of furniture.
Everything was always in the process of becoming. In response, he would
acknowledge that she was right, but insisted that his plan was also always to get to
each project and indeed, finish it, but he never did. His capacity for rationalization
and denial was immense, and his ability to amass clutter–hundreds, even thou-
sands of tools, as well as wood strips, planks, partitions, and random wood
objects–was world class. Even he was beginning to see that the rooms in the
house were filling up. Yet, this didn’t prevent him from collecting and amassing
new supplies each day. When his wife threatened to leave, and despite the fact
that it motivated him to seek treatment, he was also rather of two minds about his
111
112 17. Chaos: A Case of Compulsive Collecting and Hoarding
wife leaving home because as he finally said, “It was embarrassing for me to have
her live in that, and for her to see it every minute.”
Thus, this man knew how crazy the whole thing was, but knowing was not suf-
ficient to motivate him to do something about it. Rather, his feeling held sway and
it was this feeling of needing to do “it” that transcended any intellectual knowing.
The fact was, that this chaotic clutter collecting, was a severe symptom of com-
pulsive hoarding.
His tendency to save (hoard) things began as early as he could remember.
He always felt that to have “it,” or to save “it,” felt good. The “it,” changed from
time to time, but sometime in his late 30’s, when he began to feel good about
tools, this compulsive hoarding symptom flowered into a life’s work. He
reported that at times he felt “a little pressure” and when that happened, any tool
he could find or buy, made him feel better. He just loved collecting them. Along
with this compulsive penchant for curing his “pressure” by collecting tools, by
his early 40’s he also began collecting wood objects that he planned to utilize in
his furniture projects.
After a while, his wife would comb through the various and sundry items and
dispose of duplicates. This would anger him, but he was able to let it pass. It
reminded him of what his mother would do when he was a child and his room
became too cluttered. From time to time, he would arrive home from school, and
his mother would have cleaned it all up and actually thrown much of it away.
This would always infuriate him but he was too young and couldn’t persuade her
not to do it.
As the youngest of three siblings (two older sisters), with a span of 12 years
between him and the middle sibling, given his baby status in the family, it might
be expected that he would have been overprotected and overfed. However, what
happened was that he was underfed, undersupervised, and relatively unattended.
In addition, in his growing-up years, the patient reported feeling alone much of
the time. He was most at peace when he created games for himself and, as he said,
“collected things.” He claimed his mother would always insist on getting her own
way and that his father was weak. He reported also that his father was kind to him
but was controlled by his mother so that “he was never able to stand up to her, and
I always hated his weakness.”
For the most part, he indicated that he felt his parents favored his sisters. “No
one talked to me,” he said. He also indicated that he never felt entitled to anything
and grew up with “a humongous inferiority complex.” His response to feeling
inadequate, unentitled, and not a bona fide family member, was to develop expert-
ise in various areas. For example, he was a good artist and apparently would
spend almost all of his time drawing and painting. He also learned how to build
things and became proficient with tools. But from an early point on, he began
noticing that he wouldn’t finish things and that he procrastinated. This was espe-
cially true in school, when he would be perennially late handing in homework as
well as papers that he needed to write. He also noticed that he was “anxious a lot
of the time,” and eventually, he dropped out of high school.

The diagnostic picture indicates an obsessive-compulsive pattern with an empha-
sis on compulsive behavior. Deeper pathology is a virtual certainty, and because
the symptom was so entrenched and had become so characteristic of him, psy-
chotherapy alone, in the absence of medication, was likely to be an exercise in
futility. Similarly, use of the symptom-code would not be able to aid in resolving
his conflict and curing the symptom.
The compulsive behavior of collecting and hoarding relieved his tension.
Whenever he began to feel tense, he looked for things to bring home. If he found
something, a tool, or some wood, then he felt better, treating his tension by acquir-
ing treasures that essentially acted as medication. His act of collecting, therefore,
along with the obsessive idea he got of keeping it, successfully reduced his tension
and gave him comfort.
Of course, the reduction of tension by the compulsive act never solved the
problem, or ever cured the symptom. Rather, when the tension began to build
again, then he needed to repeat the pattern. The net result of all of this repetition
compulsion, was the ultimate saturation of all space in his living environment
with his tools, his wood, and his furniture in various stages of development.
This compulsive hoarding symptom was of a chronic nature. The symptom
usurped the main frame of his personality, and in so characteristic a manner that
the symptom had insinuated itself into his personality-trait repertoire, and
become, a symptom-trait and not merely an isolated compartmentalized symptom
sitting apart from his trait structure. The symptom was not accessible to talk ther-
apy solely, and required a medication regimen along with psychotherapy.
With respect to the symptom-code, it must be assumed that he had repressed a
great deal of anger, and that this repression originally occurred in childhood, pre-
sumably in response to his insecure sense of place in the family, perhaps in
response to his belief that he really didn’t have a place in the family, or with some
other still unknown dynamic factor of his life.
His parents’ insistence on the legitimacy of their needs and his feeling that
there existed an absence of legitimacy with respect to his needs, suggests a gene-
sis for the ostensible repression of this anger. It would necessarily mean that he
was not feeling like a bona fide individual. Under such circumstances, during his
childhood, and on the face of it, it could be assumed that for much of the time, he
must have been very angry.
Thus with respect to the ingrained nature of his symptom, a likely identifiable
candidate for the who could be one of his parents. Yet, he was never really able to
confirm this assumption of one of his parents as a sole anger-provocateur. In addi-
tion, in assessing the entire family dynamic, it would seem that his basic wish was
always to be a bona fide equal with his sisters and treated as a whole person, a fin-
ished product. As it turned out, this wish seems to have been severely restricted,
severely thwarted. In his adult life, he also seemed to feel quite unentitled, and in
fact, left everything, all of his projects, in an unfinished state.
114 17. Chaos: A Case of Compulsive Collecting and Hoarding
Of course the qualifier in any such case is that the entire psychodynamic pic-
ture is just an imposition of theory, and that this sort of difficulty – collecting,
hoarding, as well as all other such life-long difficulty – may really be an example
of a genetic or organic brain anomaly that expresses itself this way.
Taken together, his hoarding and his compulsive tension-reduction technique
of collecting, may have offered him a symbolic solution to his problem. The more
he collected and saved, the more his possessions increased and correspondingly,
the more solid he could feel. In addition, it is possible that all of his unfinished
projects perhaps served the purpose of creating the condition where the anticipa-
tion of finishing something and making it whole, meant that possibly he too could
be bona fide and whole.
Of course, this kind of repetition-compulsion of collecting and hoarding could
never make him bona fide and legitimate. Perhaps an examination of his early his-
tory, an analysis and working through of his early sense of not belonging, and a
look at what he experienced as emotional and affectional exile, could help address
his core conflict. With the addition of medication, it is possible that the compul-
sive behavior could entirely disappear. It would then be more possible for him to
work on, and at least to talk about and examine, these formative influences that, it
is assumed, were sustained in his unconscious, plaguing him his entire life.
Since his ostensible wish was a positive and direct one–to be accepted as one
equal to his siblings, to possess a sense of legitimacy–then his symptom of com-
pulsive collecting relieved his tension. Nevertheless, this particular problem, his
symptom of compulsivity and hoarding, as well as the diagnostic implication of
deeper psychotic (or brain) pathology, rendered this man unable to conduct his life
in a normal manner. He had been unable to work for many years (notwithstanding
his accident), and had been effectively unemployable mostly because, even at his
job, complaints were heard about his lateness and failure to complete work.
It may be assumed that this man’s predominant wish in childhood was to be
accepted and that this wish was thwarted. It also may be possible to assume that
he reflexively became angry at what he may have experienced as a sustained dis-
empowerment regarding this dominant thwarted wish. In such a situation where
he may have felt unentitled and not bona fide, it could be predicted that his anger,
rather than becoming directly expressed, would probably become repressed and
that the repression would have created the symptom. Thus, the issue was, what
did his symptom mean, what did it symbolize?
The amassing and filling the house with compulsively collected tools and
wood, and the hoarding of such material, leads to a rather simple symbolic con-
nection of symptom and wish. That is to say, it might be hypothesized that he
wanted to fix it all. He wanted to fix the family and fix himself; tools and wood,
build something good. But alas, it all remained unfinished, behind The Line in
withdrawal-wood, tools, and him. The wish was good, to repair his experience,
but as a symptom destined to remain unfulfilled.
Chapter 18
“Not Thin Enough!”:
A Case of Anorexia
A 28-year-old woman was hospitalized by her family after she made good on her
promise, “Maybe suicide will work for me.” She was found partly conscious in
the family garage, locked in the closed car, with the engine running. It was con-
sidered a serious suicide attempt and not merely a gesture. It was absolutely clear
that had she not been discovered in time, she would have died.
This woman was an only child, and had been anorectic, more or less, for the
past 13 years, since her mid adolescence, starting at about the age of 15. Hers was
a rather typical anorexia in which she constantly fretted about her weight, pushed
food away, weighed herself frequently, and for years, repeated her mantra: “Not
thin enough!”
Along with her fetish of thinness, she had been somewhat withdrawn, dating
also from her mid adolescence. The diagnosis arrived at in this, her first ever hos-
pitalization, was depression with chronic anorexia and high suicide risk.
This kind of chronic anorexia along with her history of withdrawal, signaled
that hers was a clinical syndrome that would be resistive to treatment, and the
anorexia symptom itself was in all likelihood an inaccessible symptom, consid-
ered to be, more or less, incurable with known existing talk-treatment technology.
Obviously, in such a case, various medication regimens would be tried in the hope
of hitting upon some miracle agent or combination of agents.
The patient stated that her most important relationship was with her mother and
that she never really took her father seriously. “He’s weak,” she said. “We patronize
him, and that’s about it.” Her mother was the major power in her life, and she indi-
cated that she talked everything over with her mother, including sexual matters.
When her mother was interviewed, the first thing she said was that her daugh-
ter hated to chew. The mother said that her daughter had never been withdrawn or
demonstrated any bizarre or unusual behavior in childhood. But from childhood
her daughter had been finicky over food, although, not anorectic.
In trying to identify some recent pivotal event that immediately preceded her
suicide attempt, as well as fix on some person associated with such an event, the
patient denied any such possible specific causative stimuli. However, in continu-
ing to trace her history from the present to the recent past, and then to the more
distant past, the patient happened to reveal that she had not gotten her period for
115
116 18. “Not Thin Enough!”: A Case of Anorexia
almost the entire past year, about eight months. In reviewing what may have hap-
pened eight months prior to her suicide attempt and hospitalization, she revealed
that she had an emotionally draining experience. She had been heartbroken
because a man she had met, who she felt liked her, and whom she very much
liked, rejected her because he actually told her she was “skin and bone,” and that
he “couldn’t do it.” He was harshly direct with her and told her he didn’t like to
lie, so that was how he felt. She was just “too thin.” Interestingly enough,
although this man told her she was too thin, her own incessant refrain for the past
half of her life was, “Not thin enough!”
When her mother was asked about the patient’s failed relationship with this
man, she indicated that the end scene was quite horrible and confirmed that her
daughter had felt terribly heartbroken over the rejection. Apparently, the patient
spent the remaining months pining for the absent partner, and it seemed to her
mother that she had not gotten over it and that, again, according to the mother, this
rejection may have been “the cause of all of her trouble.” It also seemed likely,
based upon the correlation of events, that the patient’s current menstrual inhibition
(amenorrhea), was fortified by this rejection trauma.
At first the patient was reluctant and even in protest about discussing her feel-
ings regarding this failed relationship, and especially with respect to the fact that
she was terribly hurt by it. When she did finally discuss it, a torrent of emotion
erupted. She cried and admitted to feeling devastated by the experience. Part of
her distress concerned a wish on her part to look good for this man, yet she con-
stantly felt that despite his desire for her to gain weight, she was not thin enough.
Her answer obeyed a more compelling personal inner demand, and therefore, by
default, she dismissed his feelings. Thus, rather than comply with his wishes by
gaining weight, she obeyed those personal inner commands of hers, unconscious
though they certainly were, and continued to avidly work at actually losing more
weight and therefore, getting thinner.
This woman harbored ambivalent feelings about her mother. She felt that she
needed her mother’s blessings for all sorts of daily decisions, as well as for emo-
tional support, and simultaneously she resented that she could only feel good when
she had won her mother’s approval. Any question posed to her about the pivotal
condition that ignited a suicidal impulse in her was met with a studied silence. She
would stare but not answer. Finally she admitted that a friend of hers had told her
that this man, about whom she was agonizing, was engaged and was soon to be
married. It was then, she finally confessed, that she decided to kill herself.
Apparently, this woman had developed an entire fantasy life involving this
man, and in the process of developing her fantasy, had decided that he would
change his mind and would be in touch with her. This thought would make her
feel better, and it was just about the only thing that in fact, could make her feel
better. She indicated that when her friend had told her about his impending mar-
riage, she felt “everything crashing down,” – that she really had nothing to live
for. According to her mother, at that time, she became embroiled in an argument
with her parents and shouted: “Nothing works for me. I’ve tried everything but
suicide. Maybe suicide will work for me.” In any event, her parents had not taken
what she said about trying suicide as a serious threat. They only understood it as
a figure of speech and an hysterical verbal lashing out.
Thus, the two issues that became at least somewhat clear in the distillation of
her history, in her interviews, as well as in the interviews with her mother, were:
(1) that she was exceedingly hurt by the man who rejected her; and, (2) that the
relationship with her mother contained strong dependency features on the
patient’s part, along with an imputation of power on the mother’s part. Whether or
not her mother had personal needs to control everything around her, or whether
by default, the mother was endowed with such power by her daughter, neverthe-
less, the patient was infantilized within the family. This family constellation con-
sisted of a powerful mother, an ineffectual father, and the patient herself, an
infantilized, somewhat regressed only child, who had grown up to be a dependent
woman.

The anorectic syndrome, along with her suicide attempt, were the most dramatic
components of this patient’s behavior, but which was the symptom, the anorexia
or her suicide attempt? The suicide attempt could not be considered the symptom
because it was an impulsive act that she could have modified at any time during
the process. Even if it were a carefully and thoughtfully planned attempt, never-
theless, she could have controlled it.
On the other hand, her anorexia was not something she could control. It was
habituated, and it was a consistently expressed part of her personality. In fact, the
anorexia had so embedded itself in her personality that it could be considered the
type of symptom that swallows the person whole, and then the personality
becomes the symptom. In this sense, the patient’s entire life, her personality, and
the organization of her life, literally revolved around her anorexia, which had
become a symptom-trait.
In such cases, treatment and cure of the symptom solely by psychotherapy is
quite problematic. Nevertheless, the symptom-code can be applied here in order
to examine the constituents of her symptom, also with an eye toward seeing how
the symptom cohered, and perhaps, and with some speculation, as to why it had
become so entrenched.
Focusing strictly on her anorexia and not on her suicide attempt, it would be
most likely that the who in her life was her mother. This would necessarily mean
that she was angry at her mother, repressed the anger, and what emerged from her
unconscious conflict about this anger toward her mother, was the symptom of
anorexia. But how did the anorexia symptom become a neurotic product the
purpose of which was to satisfy her basic wish, albeit in this perverse form, as
anorexia?
The answer to this question requires a guess as to her basic wish. Given the
extent of her symptom, with all of its life-threatening implications, then it must be
assumed that her anger toward her mother was of considerable strength. For one,
her extreme dependency on her mother’s approval would in all likelihood gener-
ate great anger. The principal upon which this proposition is based concerns the
relation of dependency and anger insofar as dependency always breeds anger.
Thus, because she always had been so dependent on her mother, she would cer-
tainly always have been angry at her, but at a deep unconscious level.
An example of the operation of such a principal can be seen in the psychology
of the dependency of childhood giving way to the sturm und drang of adolescence.
In addition to new hormonal activity in adolescence that usually causes such upset,
nevertheless, the many years of childhood dependency, where reliance on parents
is so great, also contributes to the outbreak of anger during adolescence. Second,
there were intimations in this case, that the patient’s mother was a controlling type.
Assuming the truth of this impression, then a strong potential for anger in the
daughter, would also surely be a possibility. Third, the severity of the symptom
also suggests that a great store of anger was being unconsciously sustained.
It would be easy to assume that because of the dependency problem in this
woman her basic wish was to become more autonomous, more independent, more
mature. Yet, it might be that the nature of the anorectic symptom implies some-
thing different. Since the dependence on the mother was so strong, and since this
implies that the repressed anger in this woman was similarly strong, then it may
have been that this woman’s wish was an indirect, negative one–an avoidant wish.
The wish may have been targeted at her needing to reduce the tension generated
by the anger; that is, the wish would be not to be angry. In this sense, the wish
would be that the anger somehow would become less intense, and not be so per-
vasive. This sort of indirect wish indicates that the symptom, in this case of
anorexia, can never relieve tension; that is, the indirect wish would produce a
painful symptom and not one that relieves tension–“Damn it, not thin enough!” It
is this kind of indirect avoidant wish that reveals what the anorectic symptom
really says.
What Does the Anorectic Symptom Really Say?

If the anorectic symptom could talk what would it say? We know that first, con-
sciously, the symptom in the voice of the patient says: “Not thin enough!” But
this observation is really a translation from another underlying language, the lan-
guage of repression, of the unconscious. Thus, when the patient looks at her
reflection in the mirror, to her eye her image is not pleasant. She thinks, “Not thin
enough!” So she tries to lose even more weight, all the while, day in and day out,
agonizing about how it’s never enough.
The point is, no matter how much weight she loses, her eyes see “Not thin
enough!” But what is it that she is really saying? The answer seems to be that
whenever she looks at her reflection in the mirror and sees “Not thin enough!” she
is really seeing, and saying to herself, while of course, not realizing it: “The anger
is still there!” The further, and even more salient point here is that one cannot
dilute or rid oneself of anger by getting thinner. However, since an unconscious
What Does the Anorectic Symptom Really Say? 119
equivalence has been construed between anger and thinness, then if one wants to
reduce anger one then goes ahead and reduces weight, tries to get thinner. Of
course, in reality, thinness and anger have no seeming discernible relation, no sig-
nificant correlation. Yet, once such a symbolic equivalence is established, there
forms an inextricable unconscious cause and effect relationship between getting
thinner and reducing anger. The problem is that this cause and effect relationship
is just that, a symbolic, unconscious, and strictly behind The Line construction. It
is a construction based on distortions, on unfulfilled needs, and on constraints that
the person feels, the solution to which is to create fantasy connections of cause
and effect–in this case, thinning out her anger. These, or course, are behind The
Line connections, connections made in withdrawal, that have virtually nothing to
do with real cause and effect but can become so powerful that such fantasy distor-
tion can constitute a path to personal destruction.
Thus, this woman’s anorectic symptom, about which she says, “Not thin
enough!” strongly implies that her reservoir of unconscious, repressed anger is
intense and deep, and that it is putting tremendous pressure on her. In an attempt
to reduce the pressure, she reduces her weight but alas, the anger remains
untouched. For an anorectic person to try to reduce the magnitude of the anger by
losing weight and of course fail at it, and then need to lose more weight, and
become even thinner, and then again not have it work, would most likely produce
a secondary anger which would then be a result of poor performance–actually,
failure. One anger on top of another is what becomes typical, so that this kind of
symptom would in this way be fortified, reinforced, and then neurotically and
consistently nourished. So, rather than the nourishment of the person, we get a
nourished symptom!
Despite the fact that such a symptom is so entrenched, nevertheless the use of
medication to neutralize some of the anger can be very helpful, and in addition,
perhaps can help provide access to the symptom via psychotherapy. Yet, in its
present form, this anorectic symptom would most likely be inaccessible solely to
therapy. In addition, in this case the symptom was of a chronic nature so that the
prognosis for an efficient recovery strictly on the basis of psychotherapy was
guarded.
With respect to her suicide attempt, we may assume that her almost-romance
with the man who crushingly rejected her also felt as though it was her only
chance of liberation from a nuclear dependency on her mother which she
ambivalently both wanted and did not want, and this hope was resoundingly
dashed. But liberated from what, from whom? Would she be liberated from her
mother, and directly into the arms of another figure upon whom she would again
depend? The hope was a false one. Her suicide attempt thus was possibly based
upon another behind The Line hope resting on the assumption that if only the
relationship with this man worked, then she would have achieved her love aim
and, in addition, become liberated from a life of infantile, regressive dependency
on her childhood parental figure. Paradoxically, however, this may have been
only half her wish–the other half perhaps being a need to remain dependent on
this self-same childhood parental figure.
Based upon this plethora of assumptions, hypotheses, and propositions, the

diagnosis of this woman also needs to consider several other factors: withdrawal
greater than that originally assumed; wishes that may have become overly
persuaded by a form of thinking that confused correlation with causation; and a
suicidal despair based less on the actual breakup of her relationship with her man
friend, and more on a distorted sense of issues related to her autonomy.
With respect to treatment issues, psychotherapy could be exceedingly useful,
assuming an effective regimen of medication, both to address the anorexia and the
depressive elements of her personality, as well as to address the ostensible pres-
ence of deep reserves of anger. Importantly, it would be necessary to pry loose the
distorted connection she presumably has made between anger and thinness.
Therefore, psychotherapy would offer her a chance to better align her thinking, to
encourage more independent action, and of course, also to lift repression, espe-
cially that of anger, or as Freud counseled, to make the unconscious, conscious.
Chapter 19
Dissociative Identity Disorder:
A Case of “Split Personality”
A 35-year-old man had been hospitalized for the second time in one year, for
major depression and withdrawal. Shortly after each hospitalization, the depres-
sion seemed to lift, and it was thought that even without medication, these hospi-
talizations tended to revitalize him. The second hospitalization was at a state
mental institution.
He worked as a handyman to clients whom his adoptive mother cared for in her
capacity as a home nurse’s aide. This arrangement apparently had been successful
for them over a period of many years. The patient would become agitated when
discussing this mother-son arrangement primarily because, when she was work-
ing, he felt deprived, actually bereft over his separation from her. Yet, it was this
mother who convinced the patient to admit himself to the hospital, and whose
requests, he confessed, he could not refuse.
At first, his diagnosis was easily decided upon because he demonstrated each
of the main constituent properties of depression. Yet, before any medication was
even ordered, his depression lifted. At the same time, however, he had managed to
acquire as well as conceal, some women’s toiletries, cosmetics, and clothing–
panties, padded bra, blouse and short leather skirt. He was eventually appre-
hended by hospital security after they found him changing from female clothing
into his shirt and pants. His problem was that he didn’t have time to dispose of the
female garb he was wearing. He did, however, manage to wipe off his lipstick and
rouge. After a chase, he was found in his hospital room with a jar of cold cream in
his hands, paper towels smeared with lipstick, and female clothing strewn on his
bed. He was being pursued by hospital security after it was reported that a man in
women’s clothing was exposing himself in full view of the windows of one of the
buildings housing female patients. He had been exhibiting himself while in full
female regalia.
When he was apprehended for exhibitionism, he was not at all depressed. An
astounding part to the story was that this man was 6 feet 4 inches tall, was a lithe
mesomorph, and was handsome and charming. On the negative side, he had a
child like innocence about him. Nevertheless, when he was apprehended, a
padded bra, a blouse, and a blonde wig with shoulder length curls, were found
under the covers of the bed.
121
122 19. Dissociative Identity Disorder: A Case of “Split Personality”
It was reported by the women who saw him, that he had pulled up the leather
skirt he was wearing, to reveal his genitals. He was apparently fully erect. Yet he
denied ever having anything to do with these female items, and could not explain
how they happened to be there, on and in his bed. In scouring his room, hospital
security also discovered a diary in his bureau drawer. The diary was essentially a
conversation; one person, a man, talking to another, a woman. In the diary, the
man explained to the woman that he felt good only when attacking others, while
the woman, in answering him, explained that she only felt good when exhibiting
her penis. And the diary went on like that, one or two pages from him to her, and
then one or two pages from her to him.
The patient denied knowing anything about the diary, and in fact, his script was
different from the script of the other two in the diary. However, evidence against
him began to mount when, along with some of the female patients’ positive iden-
tification of him as the exhibitionist, a male patient complained that he was
almost attacked by our patient for no reason that he could see, and that then our
patient was often in a foul mood, scornful and smoldering, and always, it seemed,
looking for a fight.
This unusual patient who was at first obviously under diagnosed as only
depressed, was presented at a staff conference, and in the face of patently clear
evidence, denied ever exhibiting himself. He also denied ever feeling aggressive
toward others, also here again, even in the face of eyewitness accounts. Yet, his
denials were seemingly authentic, and therefore, believable.
Thus, it was felt that his actual diagnosis, although certainly, at least containing
an episodic depressive condition, was deeper, more extensive, and implied a more
serious complex of variables. This more complex syndrome qualified as a classic
case of dissociative identity disorder, formerly known as multiple personality, and
before that, referred to in the professional nomenclature as, split personality. The
depression was then seen as secondary to the fuller picture of this possible diag-
nosis of dissociative identity disorder.
After some time it became evident that his only visitor was his adoptive
mother, who it seemed was rather inappropriate in her demeanor. She was in her
mid 50’s. She had adopted the patient when he was 3 years old. She divorced soon
thereafter and retained custody of him.
Her inappropriate demeanor consisted of a rather garish display of her figure–both
with respect to style of clothing and color. She was a vividly voluptuous woman who
wore shockingly bright clothing of a cut that would display her figure to what she
considered to be its best advantage. She admitted that the patient cross-dressed
and often even exhibited himself to her. She dismissed this as: “Some people do
this and some do that–everyone has something strange about them. He’s basically
harmless.”
The patient only gave scant information about his life and was uniformly gen-
eral in his descriptions. His only interest, it seemed, was in describing his adop-
tive mother, whom he called “beautiful.” He would regale staff personnel with
stories of how beautiful she really was, and it became clear that his only focus of
interest was on her.
Basic Formation of the Dissociative Identity Disorder (Split Personality) 123
Basic Formation of the Dissociative Identity

Disorder (Split Personality)
First, the dissociative identity disordered person is one who usually houses two
basic personalities other than the usual self, referred to as the host. Of the other
two personalities, one is aggressive and the other sexual. Theoretically, it is sup-
posed that because aggression and sex were made difficult, or even impossible to
integrate into the personality, the subject needed then to compartmentalize these
components into two other basic personalities. Reasons for the difficulty in inte-
grating the components of aggression and sex into the personality usually have
been attributed to early abuse. The abuse discussed, it is thought, revolves around
physical abuse, meaning hostile and aggressive beatings and the like. Yet, it is
also thought that an early co-opting of sexual favors can lead to similar conse-
quences. It is often the case that an incestuous parent can create a sense in the
child of feeling excluded from normal family life–actually to feel exiled, outside
the normal perimeter and parameters of family life, even though they still remain
physically within the family.
Further, the alter personalities can know of one another and of the host, whereas
the host personality, in a classic case of the “split,” never knows of the existence of
the other two. It is in this sense, that each alter develops its own memories, emo-
tions, personality style, even handwriting. In this way, the trauma experienced by
the subject during childhood duress can be partialed out of the person’s conscious-
ness, thus nullifying the psychological pain of such presumed trauma.
The self, in such a personality constellation, becomes fractured, thereby mak-
ing this kind of symptom extraordinarily difficult to treat. It should also be noted
that despite the framing of this condition as a diagnosis, the multiple personality
organization is definitely also a symptom, albeit, an all encompassing one. It is
the kind of symptom that swallows up the person whole, and it then becomes dif-
ficult to see the person as different from the symptom. It is a case in which, in
essence, the person becomes the symptom.
As the host personality develops other alters–as many as 100 have been
reported–they can all be variations on the two major themes of aggression and
sex. These other alters can be suspicious, narcissistic, or even of opposite gen-
ders. They can also take on aspects of child behavior, and any number of other
variables can determine the nature of the alter. However, it is probably the case
that all of them will be derivatives of the aggressive and sexual personas.
The shift that alters make from one to the other, is called switching, and the
range of consciousness that the host person can have of the others, can be, at one
pole, nothing at all, and at the other, some consciousness of the others. It is
thought that the purpose of this kind of psychic fracture is to disconnect from
painful memories, or even from excruciatingly embarrassing memories. Of
course, connected to these memories would be emotions and attitudes that corre-
spondingly are also parsed, compartmentalized, as it were, and placed outside of
the host’s consciousness.
124 19. Dissociative Identity Disorder: A Case of “Split Personality”
Secondary diagnoses or attendant symptoms along with the main diagnosis of

dissociative identity disorder, can consist of an entire range of typical psycholog-
ical and emotional difficulties. These can include depression, as with the patient
discussed here, lability of mood, any number of phobias, psychotic symptoms
such as delusions, intrusive thoughts, and obsessions and compulsions, to list a
sample of such standard psychiatric symptoms.

The patient presented here, in many ways, satisfies most of the criteria for the
diagnosis of dissociative identity disorder. He exhibited the classic tripartite per-
sonality configuration of a host personality housing also an aggressive type and a
sexual one. Despite his age, he was inextricably tied to his mother in a strikingly
dependent relationship. In her visits to him, his mother was so inappropriately
sexual and seductive, that to make the supposition that she was an oedipal seduc-
tress during his childhood, would not be far-fetched. Assuming this was so, the
prediction of the effect of the severity of such disturbance can be more than mere
conjecture.
Since he proclaimed no other relationships that meant anything to him, except
the one with his mother, it again would not be far-fetched to assume that she was
the who, and, by implication, that he had indeed harbored repressed anger toward
her. This, by definition, must be so, because the underpinning of the symptom-
code posits that without repressed anger, there can be no symptom. Perhaps, if he
was in fact seduced by her, and indeed felt abnormal because of it, it would not be
unusual for him then to always have been angry at her, and especially never to
have known it. We must ask two questions: What was his wish, and how does the
symptom of his disordered identity gratify that wish?
According to theory, rather than not feeling the human emotions of aggression
and sex at all, his fractured personality could have been an ingenious psychic
arrangement enabling him to configure separate compartments for these emo-
tions. Thus, his wish probably was indeed to be able to have aggressive and sex-
ual feelings even though, ostensibly, there was an outside force prohibiting it. In
cult groups, for example, the leader usually controls aggression and sex, and fol-
lowers are bound by such control. It may be that control of this patient by a sexu-
ally deranged parent resulted in the same sort of conflict regarding the control of
sex and aggression that brought about his particular personality kaleidoscope.
Thus, so that he could be whole, his wish likely could have been to contain
both aggressive and sexual feelings in his personality. Since in the symptom-
code, a positive, direct wish generates a symptom that relieves tension, then such
an inference is rather confirmed by the fact that in the split personality, this disso-
ciative identity disordered person, the full expression of whatever is the alter per-
sonality, feels good. The distinct alter, therefore, is a pure expression of its
essence, sometimes aggressive and sometimes sexual, and sometimes a variant of
these, all of which, reduce tension.
In the case of this patient, when he occupied the sexual exhibitionistic alter
role, exhibiting himself gave him pleasure, and he also felt good when in the
aggressive role, he could expostulate his anger in aggressive acts. Thus, his wish
was gratified by an organization of personality that housed three separate aspects
of his needs. The first was the host, a nice, if rather innocent man; the second, a
rather argumentative and aggressive person; and the third, a highly sexualized
cross-dressing exhibitionist.
His cross-dressing is also interesting because often in such cases, the cross-
dresser needs to disguise his manliness before he can assert it–a double dose of
disguise, as it were. The data concerning his relationship with his mother also
reflected strong dependency along with an inability to refuse her anything. This
sort of relationship could, of course, contain imperatives concerning some covert
instruction for him to remain child like, thereby denying any overt masculine sex-
ual maturity. In such a case, it could be hypothesized that his exhibitionism
would, actually and ingeniously, only occur in female form.
Of course, the entire syndrome here is a bold example of a behind The Line sce-
nario where this man existed most of the time in fantasy–albeit extensive fantasy, in
roles acted out with meticulous care. His story and his acting out of these roles is par-
ticularly poignant, especially when viewed from the vantage point of his diary. The
diary seems to have been a profound example of his loneliness. It created for him the
ability to have friends–both of his alters had become friends, and had begun writing
to one another. Despite the fact that he claimed he knew nothing of this relationship
between them, nevertheless he was the author of their relationship and therefore, on
an unconscious level he was deriving some gratification from their kinship.
This is not the kind of symptom that can be cured with the simple application of
the symptom-code. With respect to treatment, a delicate, gradual accommodation
would have to be made between his alters and himself, the host. This would neces-
sarily constitute a rapprochement among all of them, accomplished through
dialogue. He would have to get together with them, to talk about them, even perhaps,
with them. Most of all, the apparent prohibition against integrating these motifs of
aggression and sex into his personality would need to be investigated, and the distor-
tions about their dangers would have to be resolved. In addition, it may be expected
that for him to become conscious of this inner drama, necessarily he would need to
become more conscious of the experiences that were presumably repressed.
The original problem may concern his anger regarding the entire circumstance
of the hypothesized cooption in his early life. Despite the presumed trade-off he
made, that of giving up sex and aggression so that he could have his wish (exclu-
sive rights to his adoptive mother and her likely seductions), nevertheless, for him
to have developed such a complex symptom picture, points to an enormous
amount of repressed anger toward this who.
The key to the entire picture therefore, seems to be an ostensible repressed
anger toward his adoptive mother. This may be what is repressed in the deepest
psychological sense, and at some point, along with other therapeutic work, would
need to be made conscious in order to create for this person a new synthesis
regarding a possible transformation of a fractured self into a whole one.
Chapter 20
An Asperger’s Mind:
An Examination of the Case
of Nobelian John Forbes Nash, Jr.
A biography of the Nobel Prize winner John Forbes Nash, Jr. was written by
Sylvia Nasar and published in 1998. The book, A Beautiful Mind won a National
Book Critics Circle Award for biography, and a film based on the book, was also
an Academy Award winner.
Dr. Nash was, by all accounts, considered to be a mathematician of genius
whose intuitive abilities as well as his knack of utilizing novel ways of solving
seemingly insoluble problems, engendered accolades. He was also considered by
his colleagues to be so extraordinarily special that for most of his professional
life, and despite his incapacitated psychological/emotional condition, various
institutions and many colleagues, bent over backwards to support him, subsidize
him, and even offer him intellectual professional shelter within their respective
institutions.
Many of his colleagues as well as others, recognized that he was at least, odd.
Many attributed this odd quality to his idiosyncratic genius, and much of what was
considered a social inappropriateness, was overlooked or forgiven or just tolerated.
He was occasionally abrupt with others, or could not or would not look directly at
the person he was talking to. He could say things, quite unselfconsciously, that
were so rudely direct as to embarrass, hurt the other person’s feelings. For exam-
ple, during a period when Professor Nash was trying to reconcile with his out-of-
wedlock son, John David Stier, whom he had for the longest time neglected, Nash
became critical of him suggesting that John David’s profession of nursing was less
than a stellar achievement, and that what he should really do is go to medical
school. Further, Nash also suggested that it might be a good idea for John David to
look after, and care for, John David’s younger half-brother, John Charles, who was
Nash’s legitimate Ph.D. mathematician son, who was schizophrenic. As reported
by Nasar in A Beautiful Mind, instead of trying to harmonize his own proposed
union of the half-brothers, Nash, on second thought, then quite directly said to
John David, that in reality he didn’t think it would do his schizophrenic son any
good to be around a “less intelligent older brother” – meaning John David, the son
to whom he was talking.
This absence of empathy or strange relatedness, was typical of Nash. At
best, these were genuine, authentic examples of a kind of socially aberrant
127
128 20. An Asperger’s Mind: An Examination of the Case of Nobelian
understanding, and at worst, they could be considered examples of Nash as a

socially challenged person based on a developmental arrest or particular devel-
opmental pathology. It is no doubt that Professor John Forbes Nash, Jr., whatever
his true diagnosis, was, at least, socially challenged.
Along with this social awkwardness, Dr. Nash was also reported, as stated, to
have difficulty in making eye contact with others, as well as not being very versa-
tile in establishing peer relationships. Thus, his ability for emotional reciprocity
was suspect. On a firmer foundation with respect to pathology, he was ultimately
diagnosed with schizophrenia, along with manic-depressive illness. He displayed
delusional thinking and experienced auditory hallucinations that plagued him for
most of his adult life.
Diagnosis
Although indeed, Nash was afflicted with schizophrenia, as well as experiencing
bouts of mania and depression, nevertheless, the vast amount of clinical evidence
actually suggests a more relevant diagnosis–that of Asperger’s syndrome. As a
diagnosis Asperger’s syndrome may be more relevant because it seems evident
that the diagnosis of Asperger’s underlies the more symptomatic elements of his
schizophrenia, his mania and depression, as well as the oddities of his behavior
noted throughout his life, by many of his family and acquaintances.
Asperger’s Syndrome
In the 1940’s, this syndrome was formulated by a Viennese pediatrician, Hans
Asperger. It is now considered to be among the spectrum of pervasive develop-
mental disorders (PDD), and many professional psychiatric personnel, consider it
to reflect high- level autism with neurologically based implications.
Most Asperger individuals show deficits in several broad categories of function-
ing, although variations on these themes are also quite common. Deficits in social
relatedness usually characterize one of these categories. Another concerns a rather
restricted and narrow, yet entirely intense corridor of interest in some particular
subject matter. With Nash, this laser-beam corridor of interest was mathematics.
Further, Asperger individuals are frequently found in professorial positions or
in professions that imply above average I.Q., and they also frequently demon-
strate great talents in one or another area of functioning. In childhood, these kinds
of people do not make friends very easily, and are loners. They are, however, usu-
ally immersed very early on in whatever is their particular narrow interest. In
John Nash’s case, it was science in general and mathematics in particular that
attracted his attention early on, and fully absorbed his time.
Such children seem to exclude everything else from their daily interactions and
even their daily conversations. Also, many Asperger children will express an
abiding interest in cars, trains, and other transportation venues. In Nash’s case, it
Asperger’s Syndrome 129
was math that transported him. Mathematics was the vehicle of his cerebral geog-
raphy, his mind, that he utilized, to travel. It could be said that he was always on
some math excursion. As a matter of fact, when later Nash became schizophrenic,
he may have expressed this inner signal to travel by externalizing it, and actually
doing it. He literally would traverse continents, seemingly quite impulsively. Of
course, it could be that out of the tyranny of his delusional state, he did this trav-
eling to and fro, often, and for reasons that seemed entirely woven out of the fab-
ric of his delusions–his inner distortions, fantasies, and even hallucinations.
In many individuals with Asperger’s syndrome, one sees either an evident
timidity as a permanent character or personality trait, or an impulsive aggressive-
ness. In some cases, these polar opposites coexist. On the one hand, the person
can be quite timid and this quality can take various forms; it can appear as humil-
ity, shyness, reticence, modesty, diffidence, and so forth. On the other hand, along
with this cluster of timidity traits, there can also simultaneously exist an impulsiv-
ity, a narcissistic greed, and an aggressiveness. In Nash’s case, it seems that both
existed simultaneously. He was timid, shy, modest, even childlike, while also at
times demonstrating belligerence, stridency, impulsivity, provocativeness, and
aggression.
A hard-core characteristic in the diagnosis of Asperger’s is an absence of delay
in cognitive functioning, or language development, and the person easily shows
the ability to work in his own interest. Certainly, Professor Nash met these required
diagnostic conditions of Asperger’s. In addition, and as stated, he exhibited certain
social impairments, including a poor understanding of social cues, and, frequent
inappropriate emotional responses. Thus, to diagnose him with a serious disorder
of empathy seems justified because his response style could be defined as one in
which the person suffers with such a sufficient absence of empathy.
Dr. Nash also had an iron-clad will that was governed certainly more by his
internal signal than by any external reality cue. This willfulness, was imposed on
others as much as it was self-imposed, and in addition, was a greater imperative
of his personality than was any consideration of empathy toward others. In fact,
later in life he was able to ignore the compelling force of his auditory hallucina-
tions by sheer will-power. He refused to comply with those ever-present voices of
his hallucinations. Only the willpower of an Asperger’s mind would likely be able
to accomplish this considerable emotional/cognitive feat.
With respect to language, rather than showing prosody difficulties–intonation,
rate of speech, inflection–he was quite proficient in his use of language and could
and would spontaneously create brilliant puns. He displayed excellent command
of language, and just for the fun of it, even created several interesting strategic
games.
Although, Asperger’s is not considered curable, symptoms can become either
greater or, less visible as the person ages. In addition, Asperger individuals often
marry and have families. They are usually not terribly good at it, but with an
understanding spouse, the marriage can be managed and even sustained, although
under continued stress. Nash’s marriage qualifies in this respect, although his
wife, Alicia Larde Nash, eventually divorced him after almost a lifetime of such
emotional and psychological stress, struggle, and strain, along with, it should be
noted, extraordinary, even uxurious devotion.
The Proposed Deep Structure of Nash’s Schizophrenia

Yes, John Forbes Nash, Jr. was schizophrenic, but, his schizophrenia was in all
likelihood, an overlay to a highly probable basic Asperger condition. It was the
Asperger’s that was fundamental to his personality. All else, it is proposed was
accompaniment, including any mania or depression.
Several questions beg to be asked. First, what was the pivotal event that trig-
gered his first schizophrenic episode? Yes, there must have been a pivotal event!
Second, who was the person involved in this pivotal event? Yes, there must be a
who in the pivotal event! Third, what was Nash’s purpose in becoming schizo-
phrenic? Yes, there can be a purpose to the schizophrenia! Fourth, with respect to
the symptom-code presented throughout this volume, what was his thwarted
wish, and what can be deduced with respect to the assumption that, in order to
develop this overlay of symptoms, he needed to repress an enormous amount of
anger and rage? Yes, we can assume he had a thwarted wish, there was a who,
and he did repress anger.
Dynamic Elements of Nash’s Problem

It could be that the story begins with Nash’s grandiosity. His particular brand of
grandiosity seems to have contained two elements. The first, his genius in mathe-
matics, was confirmed time and again, so that his notion of himself as a genius of
great consequence had a solid grounding in reality. The second element con-
cerned the extent of his grandiosity. It would seem that Nash wanted to be recog-
nized, not only as a genius, but as the genius. There is evidence to believe that
Nash’s pathology with respect to grandiosity consisted of a classic megalomania,
but because of the true extent of his genius, at least an aspect of his megalomania
contained a profound non pejorative implication.
Among his many accomplishments were solutions to great and vexing prob-
lems both in pure and applied mathematics, and his method for understanding and
solving such problems was recognized as unusually brilliant. For example, at one
point he transformed nonlinear equations into linear ones and then solved the
equations by nonlinear measures. He would translate one language to another
and then return to the original language in order to understand the deeper struc-
ture to the translation, ultimately solving the original problem. It is something
like a painter taking a photograph of a painting and then doing a painting of the
photograph in order to somehow animate the original work. In each transforma-
tion, interesting changes can be noted that perhaps then can reveal a different syn-
thesis of the work. In addition, it’s probably fun to do these transformations. At
least by analogy, it is proposed that the great fun Nash had in life concerned his
Dynamic Elements of Nash’s Problem 131
absorption in mathematical conundrums, the more complex, the better. It is as

though his brilliance needed the very complex and most difficult challenges to
stimulate his, and its, motivational juices. His ability to stay with a problem was
remarkable. His attention was reflected in his persistent focus, and such prob-
lems, apparently without exception, evoked his intuitive powers. These chal-
lenges, and the promise of vanquishing them, or the anticipation of the moment
when the solution would hit him, these expectations, seemed to nourish him.
Nothing else seemed to matter as much.
And then there was the Riemann. The Riemann Hypothesis regarding prime
numbers, was a problem of staggering proportions. It has been considered to be the
most visible, perhaps outstanding problem in pure mathematics and theoretical
physics, certainly successfully rivaling that of Fermat’s Last Theorem, or even any
proposed revision of quantum theory, which Nash, incidentally, also considered
tackling. This hypothesis was proposed in the middle of the nineteenth-century by
the great mathematician, George Friederich Beinhard Riemann. It was an attempt
to unravel a deep truth about whole numbers. These prime numbers can only be
divided by themselves, and they seem implicated in the puzzle concerning the
reconciliation of Newtonian and quantum physics.
Thus, Nash’s psychic investment was with the Riemann, and he decided to
take it on. More accurately, it looks as though Nash decided not only that he
would take it on, but that he would be the one to solve it! He tried every which
way: by utilizing number systems; by applying logic of internal consistency;
and, by other accounts, of even trying what some called, “wild approaches.” If
there ever could be a precipitator for Nash’s schizophrenia, perhaps it would be
the internally imposed pressure he would have been bound to experience in the
pursuit of as important a problem as the Riemann, especially in the face of his
failure to solve it.
But Nash did not become schizophrenic merely as a result of some kind of
fracture in his psyche that broke him down; that would be too prosaic. No, a
genius does genius things. And this genius perhaps may have been trying to solve
the Riemann by becoming schizophrenic. He intuitively may have been trying to
implement his intuition as he did with the transformation of nonlinear equations
into linear ones, and then solving the problem by nonlinear measures. Thus, per-
haps in this new schizophrenic thinking persona, he could do something that:
(1) no one else had ever done, or perhaps would ever do; and (2) would then
generate acclaim for doing something that would gain him a consensus as perhaps
the greatest genius that ever lived-the ultimate confirmation of the validity and
logic of his grandiosity. A megalomaniacal confirmation, with a hue even, as
stated earlier, of the nonpejorative.
Such was his voracious focus on the Riemann. But alas, even in his translated,
or transformed state, his schizophrenia, he couldn’t do it, and he didn’t do it-ever,
or perhaps even, yet. He knew that others were working on it, and even before he
became floridly schizophrenic, he knew who some of those others were. Once he
was schizophrenic, however, and his psyche was therefore in its fractured state,
even a person as singularly brilliant as John Forbes Nash, Jr. could not or would
not, reconstitute himself. Delusions and hallucinations would then haunt him for
years to come.
But even in his schizophrenic state, his struggle with a great problem like revis-
ing quantum theory or solving the Riemann, as well as his struggle with his mega-
lomania was not over. He had also become incoherent and was exhibiting classic
schizophrenic delusional thinking. Yet, even though his behavior seemed random
and sick, nevertheless, it could be that all of it, all of his seemingly random, sick,
pathological, paranoid, delusional thinking, revolved around, and made perfect
sense, when viewed from the perspective of his ostensible megalomaniacal strug-
gle with the great problem of the Riemann. There are many such examples of this
struggle, but for the purpose of this exposition, two or three such examples should
suffice.
The first example of the connection between his floridly schizophrenic symp-
toms and this presumed struggle with the Riemann, concerns Nash’s obsessive
and intrusive thoughts about seeing codes in newspapers and magazines. He
would clip these articles and apparently plaster them all over his life. What he was
doing was most likely using this delusion as a template in order to see the osten-
sible coded meanings from these articles. But what did this behavior really mean?
One possible, and perhaps not very far-fetched hypothesis, is that his obsessive
focus on newspapers (in order to receive their coded messages) was really an
attempt to connect the coded messages to the solution of the Riemann. In fact, his
repetitive, insatiable pursuit of these articles, and more importantly, the satisfac-
tion this pursuit and these articles afforded him, indicated that getting these coded
messages was his unconscious confirmation that he had indeed solved the
Riemann, or was now about to. His basic wish was to solve the Riemann and his
schizophrenic pathological musings and behaviors could likely have reflected a
multitude of gratifications he derived each time he clipped an article or saw what
he deemed to be a coded message. All of it could well have been about finally
finding the solution to the Riemann. With all of these daily clippings, he could
then solve it over and over again, a classic perseveration. And the concrete collec-
tion of these articles was his proof positive, that he was, in fact, doing it, and
doing it, and doing it, solving it over and over.
Thus, all of his obsessional thinking as well as compulsive behavior regarding
coded messages and clipping articles, rather than reflecting some random, crazy,
and schizophrenic cognition, could now be seen as Nash’s quite original and even
brilliant solution to his conflict–an ingenious solution perhaps rivaling that of
actually solving the Riemann. It possibly could be called The Magnificent Nash
Synthesis.
This “Magnificent Nash Synthesis” would mean that the conflict no longer
concerned the solution to the Riemann. Rather, his conflict was now resolved by
figuring out a solution to not being able to solve the Riemann. In other words,
Nash was so brilliant that because he couldn’t solve the Riemann, then rather than
solving it, he derived a way to solve the problem of not being able to solve it, and
therefore, he was able to retain his megalomaniacal belief in his infallibility as a
genius-the greatest genius.
Dynamic Elements of Nash’s Problem 133
What he may have done was to figure out a way to erase the Riemann as a
problem by derealizing it. Assuming the validity of this conclusion, (tentative
though it may be), the speculation here is that Nash’s approach to erasing the
Riemann, was to find the code in the magazine or newspaper, and clip the article.
Article clipped-problem finished! This kind of solution to his conflict, given his
schizophrenic condition, could be considered an overarching cognitive/organiza-
tional achievement, a feat of major proportion. Again, the problem was no longer
the Riemann. The proof of his genius now, was that Nash had figured a way of
retaining his grandiosity because he couldn’t solve the Riemann. Thus, the great-
est problem in mathematics was not the solution to the Riemann. The greatest
problem in mathematics was in not solving it. Through a psychological transfor-
mation, Nash wins by not solving it.
As indicated, his initial answer to these supra and super cognitive/organiza-
tional achievements, was in the appearance of his transformed state, in the
appearance of his schizophrenia. It may have been Nash’s way to make something
visible (in his schizophrenic state of seeing coded messages) that could perhaps
not be visible in any normal thinking state. But he was not able to accomplish this
intended goal of seeing some unusual path to the solution of the Riemann via his
schizophrenic persona.
Thus, with respect to actually solving the Riemann, this schizophrenic transfor-
mation did not work. The only thing that worked was his Freudian acted out
repetition-compulsion that never really mastered his anxiety. Rather, this repeti-
tion behavior only mastered his acting out of the conflict. In a practical sense
then, in his schizophrenic state, his solution was to hear voices and become delu-
sional about coded messages. And in these coded messages, was his perseverating
solution to the Riemann. This was a schizophrenic perseveration of the first order,
serving to gratify his need for a successful Riemann closure. Yet, this solution
was enclosed in his even greater supra cognitive/organizational feat of erasing the
Riemann altogether.
If this rather speculative scenario has some validity, then for him to remain
schizophrenic would be an imperative in order to continue to disarm the grenade in
his stomach at not really solving the Riemann. Remaining schizophrenic, there-
fore, was to control, erase, and solve the Riemann, all at the same time. An ingen-
ious Nash paradox!
Another example of this kind of logic to the retention of his schizophrenia, to
his unconscious organization, and to his confluence of thinking and behavior, also
lending a kind of support to this theory of how Nash managed both to solve and to
erase the Riemann, concerned his attempts to renounce his United Stated citizen-
ship. He went to considerable lengths, over a long period of time, trying to do this.
A possible answer as to why he would do so, again concerns his failure to solve the
Riemann, along with another way of erasing the problem altogether. A possible
hypothesis is that in his unconscious he could have posed an equation; that is, as a
United States citizen, his mission was to solve the Riemann, which he wasn’t able
to do, so that naturally, to renounce his citizenship, could mean that he no longer
felt the mandate to solve it, and therefore was off the hook. Thus, no mandate, no
Riemann, no agony. Under such a condition he could retain the full measure of his
megalomania. “I am still the greatest genius,” would be the surviving mantra
because as a citizen of another world, the Riemann would not even exist!
A third hypothesis regarding his schizophrenia and its purpose, other than actu-
ally serving a compensatory need with respect to his actual failure in solving the
Riemann, or to whatever extent a schizophrenic predisposition may have existed,
concerns the relation between his basic presumed Asperger’s state on the one
hand, and the serious realistic challenge that he very likely experienced regarding
his self-appointed megalomaniacal genius role, on the other. It must be realized
that in Asperger functioning, despite the fact that such individuals can indeed
have relationships with friends and family, the individual’s basic relationship is
with the self. When the experience as well as the belief tells the individual that a
profound failure has occurred, a challenge emerges to this sort of narcissistic
arrangement of the self. Thus, a challenge of the relationship of self to self is cre-
ated. In the face of such a challenge, the Asperger individual has been forsaken.
In this case, because of his failure to solve the Riemann, his grandiose self would
have been subtracted from itself, and under such circumstances he would then
have felt quite alone; feeling that perhaps he was not, and had never been the
greatest genius he had hitherto believed himself to be. The problem is that in such
a narcissistic, no less megalomaniacal Asperger’s condition, when one is not the
greatest, then one is nothing.
In Nash’s case therefore, a truly remarkable and actually superbrilliant solution
would have been for him to get a friend for his Asperger self. And that friend may
well have been a schizophrenic one–John Forbes Nash, Jr., Asperger individual,
in concert with John Forbes Nash, Jr., schizophrenic individual. If this is so, not
only would it be that Nash is a mathematical genius, but for all intents and pur-
poses, he would have to be considered a psychological one as well, notwithstand-
ing the fact that the genius of his psychology would be to keep himself in a failure
free state; that is, in a schizophrenic state with different citizenship, and therefore,
of course, away from the Riemann.

The key here is identifying the who with whom Nash was, and perhaps still is,
angry. We know that emotion must take an object, and that the object is always a
person. Thus, he must be angry with a person. Or must he be? These axioms
apply to individuals who are normally neurotic but do they apply to Asperger
individuals? The answer seems likely to lie in a particular characteristic of the
Asperger’s symptom; that is the Asperger individual usually focuses on part-
objects. Therefore, a theoretical half-step can be made, a fissure reveals itself,
with respect to these axioms as they may apply to such Asperger individuals,
namely, that inanimate objects are often personified. These inanimate objects are
therefore subject to vitalization, to a symbolic animated existence usually, in part,
as in part-object.
It is thus proposed, that this may have been the case with Nash and his intellec-
tual, emotional, and psychological focus, or actual fusion with the Riemann. He
personified the Riemann as though, quite naturally, it was a person. When he
could not penetrate the problem of the Riemann, however, rather than becoming
furious at the person who was thwarting his basic wish to solve it, he may have
become enraged at the Riemann itself. The Riemann would have been the object
of his thwarted wish, and rather than knowing it consciously, he would have
repressed a great magnitude of rage toward the Riemann. The index of this mag-
nitude of rage would most likely be determined by the same magnitude of his
megalomania. This is because at the core of the megalomania, is the megalomani-
acal wish, a wish of maximum intensity, perhaps equivalent to the wish for life
itself. Thus, in the face of the thwarting of this wish, the rage would necessarily
have had to have been atomic. This rage would have been enormous enough to
create an implosion, so much so that he would have been left with rage-debris
spanning, covering, and penetrating his psyche, equivalent to a permeating, per-
vasive radioactive contamination.
This then, could have been the basis of his schizophrenic meltdown. All of his
schizophrenic symptoms, therefore, would be derivatives of this basic conflict;
namely, love of the Riemann, and simultaneously, hatred of it. Expecting to solve
the Riemann and thus confirm his grandiosity, and the actual failure to solve it,
and an equally deflating blow to his megalomania. All of it created an ingenious
way of both erasing and solving the Riemann simultaneously, albeit through a
schizophrenic distortion.
Part of Nash’s schizophrenic amalgam of distortions and hallucinations, included
anti-Semitic sentiments. Here, it could also be hypothesized that, along with his
other symptoms, all of which served the purpose of managing his megalomaniacal
fury regarding his real failure to solve the Riemann, his anti-Semitic rantings were
defensive machinations designed to isolate and nullify any credence given to
Jewish genius. This speculation is based upon his experiences as a mathematician,
often encountering Jewish scientists whom, he knew, were brilliant. In addition,
Nash also occupied a place at Princeton, and despite his admiration of Einstein, in
no way could he not have been envious of Einstein’s stature in the world, certainly
in popular culture, as the greatest genius of all. In this sense, the way Nash could
eliminate any possible challenge to his own megalomaniacal assumption as being
the greatest of all, would be to necessarily nullify Jews generally and Jewish scien-
tists in particular. It is proposed that if not for this schizophrenic megalomaniacal
state of failure regarding the Riemann, Nash’s focus would be on his work, and his
relationship with Jewish friends or colleagues may not have had the slightest tinge
of anti-Jewish feeling whatsoever. Perhaps the only issue was his conviction that if
any scientist was going to solve the Riemann, the likelihood was that that scientist
would be a Jew; a Jewish scientist, genius, of whom he knew many. To Nash, some-
one other than himself solving the Riemann was probably equivalent to psycholog-
ical or emotional death. Since he may have believed that a Jewish scientist was the
one likely to do it, then Jews were generally no good – to be negated.
Of course, before the onset of his schizophrenia, and despite his Asperger state,
he still lived within, at least the minimal limits of normalcy. He had a family. In
this respect, despite his Asperger condition, he made some attempt to care for a
number of people. Nevertheless, it could be that in his personal, subjective sense
of self-importance, his narcissism and megalomania called him to the Riemann,
and it very well may have been that this focus prevailed as the defining circum-
stance of his adult life.
In addition to these speculations, it could be that there was another person,
probably a mathematician, who could also qualify as a support person with
respect to who could have been the original focus of Nash’s anger – the human
who. If this is so, such a person would have had to play an important role in
Nash’s emotional life around the time of his slide into greater pathology.
Treatment
In the treatment of this complex person, Professor John Forbes Nash, Jr., involv-
ing Asperger’s imperatives and a schizophrenic overlay, it is possible that the
schizophrenia may, in effect, be urged to a point of remission, or at the very least,
be neutralized. This is a clinical possibility based upon the assumption that
Nash’s schizophrenia, despite the fact that his son, John Charles, was also schizo-
phrenic, could be a functional impairment brought on by emotional pressures, and
necessarily by the appearance of some epigenetic pathology awaiting its develop-
mental time and pivotal circumstance, to reveal itself.
The same cannot be said of his presumed Asperger’s condition. The Asperger’s
complex would have had to have clearly been with him from birth. In any therapy
treatment, Nash would have to begin to see the connections between his narcissis-
tic megalomaniacal great-man inner Asperger’s tyranny, and how it would not per-
mit his tyrannical self to be a lenient inner self. Rather, this tyrannical Asperger’s
inner self which may have needed to have him be the greatest of all, would have
mercilessly pushed him to render his most ingenious solution to any problem he
ever tackled. In Nash’s case, this attempt at an ingenious solution may have been to
repress his rage toward the Riemann and then to develop a schizophrenia in which
each and every symptom of this pathology reflected part of a strategy he uncon-
sciously used: (1) to think of himself as prevailing over the Riemann, and when
that was not enough; (2) to try to renounce his American citizenship as an uncon-
scious way of freeing himself from the perhaps tyrannical mandate of solving the
Riemann. These circumstances may have been his only way to loosen the grip of
this inner psychic tyranny. The schizophrenia also may have been a way to under-
mine the genetic tyranny of his presumed Asperger imperatives.
Thus, Nash would need to get in touch with his anger, this proposed rage
regarding his assumed thwarted wish. Further, it is proposed that then the very
life, the very essence of his schizophrenia, would be challenged. The axiom
remains: Where there is no repressed anger, not only will there not be a symptom,
there cannot be a symptom.
Conclusion 137
The therapeutic objective with Nash, therefore, would be to implement the

symptom-code presented here, including explication of the wish, the repressed
anger, and the who, and then to penetrate the assumed meaning of his schizophre-
nia. Given his true genius, he is most likely, and happily, a prisoner of the ingenu-
ity of connections and phenomena, his own included, that would be able to be
explained to him, and certainly, without a doubt, understood by him. It is proba-
bly also true that he would have no choice but to be compelled by any powerful
theoretical organization. The point is, that a man of Nash’s scientific brilliance
and intuitive powers, might be stronger than the schizophrenic Nash, with his
morbid compensatory strategy of dealing with his Riemann demon.
Thus, given Nash’s beautiful mind, when faced with truth, and the powerful
beauty of truth – that is, being compelled by consciousness, in seeing the seduc-
tions, powers, and tricks of the unconscious, he may, under such irresistible think-
ing circumstances, then be subject to relinquishing his citizenship in the country of
schizophrenic pathology. Any remaining pathology would be a form of resistance
to knowing. In psychoanalytic parlance, resistance is merely a fortification of
repression. Even his auditory hallucinations are meaningful with respect to reflect-
ing his presumed original basic repressed wish, to solve the Riemann. Thus, the
therapeutic treatment task would be to: (1) help Nash lift this repression; (2) under-
stand the wish; (3)see that the repression is a repression of rage; and, (4) at the very
least, identify the Riemann as the very possible personified who.
The final piece in the application of the symptom-code would be for Nash to
implement a doing thing related to the original problem, presumed here to be pos-
sibly his attempt to solve the biggest problems such as the revision of quantum
theory, but more likely, his desire to solve the Riemann Hypothesis. What this
doing thing could be, would have to be worked out with Nash himself. An inter-
esting prospect, indeed, considering of course, that given Nash’s brilliance, it
could possibly be that it will be Nash himsel that figures out what this doing thing
could be.
Conclusion
True, this entire chapter is highly speculative, a metapsychological study.
Nevertheless, the theoretical synthesis seems large enough to include virtually
each and every symptom of Nash’s pathology, and possible pivotal variables have
been identified as likely culprits in the process of Nash’s decline into a bizarre life.
The symptom-code of the wish, repressed anger, the who, and a doing thing
related to the original problem, offered here as a template to understand and
organize most, and possibly all of the phenomena of Nash’s decline into pathol-
ogy, has been one way to take a great amount of anecdotal material, and a com-
plex set of pathological symptoms, and organize them into what might be an
understandable model that possibly could be utilized in a therapeutic framework,
even with Professor John Forbes Nash, Jr., this genius – a man with a beautiful
Asperger’s mind.
Part IV
Examining Theoretical Issues
of the Symptom-Code
Chapter 21
Acting Out: The First Symptom,
and the Primacy of Anger or Sex
In Part IV, a number of theoretical issues will be raised that are directed at a criti-
cal examination of various questions regarding the efficacy of the symptom-code
as a cure-all for a certain class of symptoms. Most of these symptoms were those
of recent onset, and which had not fully contaminated the personality. Thus, the
person and the symptom remained distinguishable, and such symptoms were seen
to be encapsulated in a neurotic and nonpsychotic state. This class of symptoms
was also not encrusted in a chronic somatized transformation, and in addition was
free from any neurological or biological influences. In other words, these curable
symptoms, for the most part, were those that remained in an ego-alien position in
relation to the personality.
Of course, this formulation of the difference between accessible curable symp-
toms and the more inaccessible resistant symptoms, raises many questions. We
need to ask, for example, what it is about a symptom, in the context of a psychosis,
or what it is about a symptom that has been chronically somatized, or what it is
about a symptom that has been sustained for a lifetime, which makes it relatively
immune to psychotherapy using the proposed symptom-code, or for that matter,
using any psychotherapy method at all?
There are many such issues to examine, along with questioning the basic
axioms that have been presented. After all, an axiom is also an uncontested
assumption. We need to contest the assumptions made, and examine the probabil-
ity of their so-called self- evident truths.
Is it Anger or Sex?
An indirect approach to understanding whether it is anger or sex that constitutes
the basic emotion, impulse, or instinct involved in symptom formation, can be
examined in light of the following question: In prehistoric man, what was the first
symptom? If we go back in time, 50,000 or even 75,000 years ago to the early
Pleistocene Era, to Australopithecus prometheus, could we speculate as to
whether such a being had psychological symptoms? And if so, what might the
first one have been? And further, would such a symptom be any different from
141
142 21. Acting Out: The First Symptom, and the Primacy of Anger or Sex
what we see in modern man? Of course, would this symptom have been the same
for Java man of the Pithecanthropine or Homo erectus species, of the middle
Pleistocene Era, or Cro-Magnon man of the Homo sapiens species, approaching
the late Pleistocene Era, even 30,000 years ago?
One way to understand what this first symptom may have looked like, is to
examine the axiom or the symptom-code element concerned with the manage-
ment of anger. This axiom of the symptom-code states: Where there is repressed
anger, not only will there be a symptom, there must be a symptom. This axiom is
invoked when a person’s wish is blocked or thwarted. With the thwarted wish, at
once there is created the feeling of helplessness or disempowerment; that is,
wishes that are gratified are empowering, and in contrast, wishes that are
thwarted, are disempowering. Since an accepted premise or hard core psycholog-
ical law holds that all helplessness breeds rage, then it certainly seems that in a
state of even momentary disempowerment, the evolutionary impulse, or reflex, is
to become angry. The answer to the question of why is this so is that when one is
in a state of helplessness or disempowerment, then frequently, the only way to
become reempowered, is to be angry. Anger is a release, an expostulation of
power. It may not always be productive, or even successful in actually achieving
reempowerment, and yet in that momentary state of helplessness, the release of
anger brings relief in the sense of the feeling of reempowerment.
Seen from this perspective of empowerment versus disempowerment, it seems
evident that anger, as an explosive expression of energy and power, could always
be experienced as an empowerment. The same, of course, could not be said of a
sexual impulse, which on the face of it is quite an iffy, and at best, conditional
response to circumstances of disempowerment. In fact, there is probably a very
high inverse correlation between an intense sexual impulse and an intense cir-
cumstance of disempowerment. However, the anger response to disempowerment
certainly seems, even on the face of it, and with respect to each and every person,
everywhere in the world, to be the ubiquitous response to all disempowerment.
The Primacy of Anger

Thus, in human affairs a picture of the primacy of anger begins to develop, espe-
cially when contrasted with the role of sexuality. The point is that we are all wish-
soaked creatures and wishes want gratification. These wishes of ours are also not
often ranked as to importance. Major and minor wishes are treated in much the
same way. Everything is major when the wish is wished for. In a moment to
moment discrete existential sense, and in terms of priorities of the psyche, indi-
viduals typically behave as though there may be no such thing as a minor wish.
By and large, however, even though people do indeed make some distinctions
between major and minor wishes, it would seem that the initial predilection is to
respond in a large way, to any thwarted wish.
The issue is whether, when some wishes are thwarted, and anger invoked, is the
anger then consciously retained and addressed, or is it instantly repressed, even
The Psychoanalytic Understanding of Acting Out 143
before the person is aware of its existence? If repressed, then it is proposed that a
symptom will begin to gestate, and the symptom will in turn presumably reflect a
gratification of the original wish, albeit in a transformed, neurotic, or perverse
form–the symptom. The symptom, therefore, will be the wish gratified, a Freudian
discovery of major significance. And the symptom can include anything from the
development of anxiety to a more generalized symptom of acting out.
In prehistoric man, anxiety would be the probable initial response to some real
or perceived threat, but the sense of disempowerment resulting from a persistent
feeling of danger or threat would surely have led to a chain of events, the likely
purpose of which was to generate reempowering behavior despite the obvious pro-
tective, guarded, and fear behaviors that surely existed. Further, in prehistoric man,
in the face of the existence of varieties of predators, as well as the experience of the
greater force of nature, initial anxiety would necessarily have needed to be replaced
by some motoric act in order to achieve some ambulatory possibility–some doing
thing. Again, the aim of this doing thing would be to guard and secure the self – an
attempt at mastery and therefore also reempowerment.
Thus, with respect to a generalized acting out, or even in a more undifferenti-
ated expression of a symptom, it is proposed that in prehistoric man, for example,
the first symptom may have been an undifferentiated one – generalized anxiety
transformed to a generalized acting out, based upon the repression of anger
regarding a thwarted wish, which would have been what it always has been, a
wish to be empowered; fear leading to disempowerment, leading to anger, leading
to repression of anger, leading to acting out.
The Psychoanalytic Understanding of Acting Out

In contrast to the psychoanalytic understanding of acting out, the psychiatric def-
inition is satisfied by the identification of the person’s inappropriate behavior;
that is, a person’s behavior constitutes the sine qua non of such a psychiatric
definition. The psychoanalytic definition of acting out, however, revolves around
the ubiquitous defense of repression, fortified especially in therapy sessions, by
an ever present resistance to the treatment.
Thus, in psychoanalysis, acting out is seen as an attempt not to know something
(via repression) by invoking doing (acting out) behavior. The process of not-
knowing is accomplished through the use of repression. Therefore, when anger is
repressed, the not-knowing is achieved by keeping the person out of touch with
this self-same anger. In the most general undifferentiated sense, whatever symp-
tom appears thereafter is an example of acting out; that is, doing, instead of know-
ing, the classic psychoanalytic understanding of acting out.
It would seem from this concatenation, that even in prehistoric man, the first
symptom process must have been a morphing of initial anxiety and fear, generat-
ing endless disempowerments, and then to generalized acting out of anger. And
the acting out, as stated, would have been based upon the repression of such
anger. In prehistoric man, repression of anger was, at times, most likely the only
choice. In all likelihood, acting out became the expression of a psychic equation,
that is, the acting out was in symbolic form, an attempt to gain the wish, to gratify
it. As man evolved, symptoms became gradually more specific, more differenti-
ated, until a profusion of adaptive possibilities emerged in the form of psycholog-
ical/emotional symptoms–from phobias to panic attacks, from obsessions and
compulsions to somatized symptoms, and from delusions and hallucinations to
any number of intrusive thoughts or even any number of psychotic regressive
behaviors.
Thus, in this probabilistic theoretical examination of the management of anger,
the repression of anger, the nature of acting out, the experience of anxiety, the
relation of the wish to anger-repression, the nature of the symbolic equation of the
symptom to the wish, the psychology of empowerment and disempowerment, as
well as attempting to derive some clue as to the nature of symptoms from the
dawn of human evolution, from all of this it seems that it is anger and not sex, that
is the linchpin of symptom formation.
Abridging Traditional Psychoanalytic

Understanding of Symptom Formation
In the conventional understanding of symptom development, the ego is in the dri-
ver’s seat insofar as it is felt that the ego has to be strong and resilient enough to
control the drives. These drives are considered to be id impulses. In conventional
psychoanalytic theory, when symptoms appear, it is the drives that become impli-
cated insofar as a conflict then develops between the ego, the control, and the id,
the impulses. This conflict is then theorized as really being a compromise
between the derivative of the drive on the one hand, and the fear regarding a sense
of danger that emerges with respect to the breakthrough of the drives, on the
other. In psychoanalytic theory, this compromise is formulated as the symptom.
Thus, in psychoanalytic understanding of the drives, these id impulses are
thought of as both aggressive and sexual, implying always that either or both are
responsible for generating symptoms. In the symptom-code presented in this vol-
ume however, and in the associated conceptualization of the nature of symptoms,
this psychoanalytic traditional understanding of symptom formation would seem
to need amending.
The challenge offered by the conceptualization of the present symptom-code
and its underlying principles and axioms, would strongly argue only for anger as
the derivative of the drive implicated in symptom formation. Of course, there can
be sexual wishes that are thwarted, but that does not mean that it is the sexual
repression, suppression, or frustration that is causing the symptom. When a sex-
ual wish has been thwarted, like any thwarted wish, disempowerment or helpless-
ness results, and it is this helplessness or disempowerment that will generate
instant anger, conscious or not. It is this anger that when repressed, will generate
the symptom. Again, a frustration of a sexual wish produces the same anger as
does a frustration of a nonsexual wish, or any wish, for that matter. It is the anger,
Illustrations with Clinical Vignettes 145
in response to thwarted wishes, that is ubiquitous in the formation of symptoms,

not the sex.
In fact, it is proposed here, that never is the sexual impulse directly responsible
for the formation of a psychological symptom. Only the repression of anger, and
no other emotion, impulse, or drive, is responsible for the formation of symptoms.
It is anger that is the linchpin because it is anger that is always invoked to manage
the thwarting of wishes. The answer is not whether it is sex or anger that consti-
tutes the key to the symptom process. The key to the symptom process only
involves whether the anger is repressed producing a symptom, or not (producing
no symptom). Now the axiom is formed: If the anger is not repressed there will be
no symptom. If the anger is repressed, not only will there be a symptom, but there
must be a symptom.
Despite this insistence on the primacy of anger and the pointed irrelevance of
the sexual drive to the actual mechanics of symptom formation, nevertheless in
the psychoanalysis of any patient, all sorts of historical analyses based on psycho-
sexual stage considerations, as well as considerations of intrapsychic conflict,
certainly still obtain, and these remain requisites in the understanding of the entire
picture contributing to the analytic working-out and working-through process. If
there is any emendation to be made, it is only with reference to clarifying what
goes into the mechanics of symptom formation, and that is anger, not sex.
Illustrations with Clinical Vignettes

Brenner (1974), in contrast, offers examples of how sometimes it is the sexual
implication that forms the symptom. He presents a clinical vignette of a mature
woman who developed a symptom of vomiting. The interpretation given essen-
tially accounts for the symptom as a reactivation of the woman’s historical wish,
during her early oedipal years, to be impregnated by her father. Her father’s
remarriage in the period of the woman’s then adult life, ostensibly caused the
vomiting symptom. By vomiting, she would deny her father’s new marital situa-
tion and its sexual implication. By vomiting, she was essentially saying, “See, I’m
vomiting. I have morning sickness.” Hence, it is concluded that the woman used
the vomiting symptom to gratify the original wish, in symbolic symptom form to
have been impregnated by her father.
This is all well and good – but does it reflect a true dynamic? It could be that a
different but related scenario is actually closer to what happened. For example,
the woman could have resented that her father remarried for any number of
reasons, even, or perhaps especially, for the reason regarding her reputed histori-
cal wish to be impregnated by him. Yet, it is more likely that she then repressed
her anger about her father’s new marriage, either because of abandonment feel-
ings or because of the threat of losing her historical wish, or because a conscious
objection would be embarrassing, or whatever. The important point is not that she
repressed her sexuality, but that she repressed her anger about her father’s mar-
riage, or even about her ostensible unrequited sexual wish. In any event, because
she very likely would have been angry about his marriage, then anger and not
sexuality would be the key emotion that became subject to repression
Her father was the who, who was making her angry by his behavior – he mar-
ried. Her wish was to keep him unmarried, so she began to vomit. The vomiting
was more likely an attempt to expel, to rid herself of this new formation, this mar-
riage. Of course, since the wish was an indirect avoidant one (for him not to
marry), then it would be predicted that her symptom would be unpleasant and not
pleasurable. Vomiting is not pleasurable.
Thus, in this case, her statement, “See I have morning sickness,” as a message
of the symbolic gratification of her wish may indeed be an accurate reflection of
the correlation of the wish and the symptom. Nevertheless, to consider this con-
nection to be a possible result of some sexual repression would, at best be tangen-
tial, and at worst be wrong, a tortured explanation and an incorrect explanatory
stretch, at best. It is the repression of anger regarding the thwarting of her basic
wish with respect to the who, her father, which reveals the mechanics in the birth
of her vomiting symptom. It is this equation of the repressed anger to the who,
that connects her wish to the symptom–and, it is proposed here, nothing else.
In another vignette (Brenner, 1974), a soldier developed an anxiety attack while
on the front lines, and had to be removed from battle. This case also exemplifies
how the repression of anger generates the symptom. The soldier’s anxiety attack
would be considered to be merely a symptom of the wish to flee the front line of
danger. Parenthetically, anxiety attacks as symptoms would be always considered
a result of repressed anger to some condition of helplessness. These sorts of
attacks would be defined as fears or panics only on a manifest, concrete level. The
soldier’s helplessness or powerlessness presumably developed out of a sense of
vulnerability on the front lines. Yet, most certainly, such helplessness always gen-
erates anger that then, because of the appearance of the anxiety attack necessarily
implies that the soldier’s anger was repressed. Without the repression, the anxiety-
attack could not have crystallized, because, according to the understanding consid-
ered here, in the absence of repressed anger, there cannot be a symptom, including
an anxiety attack.
With the repression of anger, anxiety emerges as a gratification of the wish to
be protected. The anxiety above, is here seen as radiating from the repressed
anger below, thereby satisfying the wish to escape danger. Since each basic emo-
tion such as fear or anxiety contains its own fundamental nature, then when one is
anxious or fearful, fleeing is the only wish that expresses the unidimensional
nature of that particular emotion. Thus, in the case of the soldier, repressed anger
produced an anxiety condition that then enabled the person to become removed
from the perceived threat – wish gratified.
And this entire issue reveals a profound psychoanalytic implication that seems
to invite, or strongly suggests, a revision of the Freudian understanding of symp-
tom formation. The revision is expressed in the symptom-code; that is, the
thwarted wish produces a sense of powerlessness that generates anger as a
method of reempowerment. This anger when becoming instantly repressed, in
turn, generates a symptom that is a perverse or neurotic way of gratifying the
Summary 147
original wish. And this process does not depend on which psychosexual stage the
original historical material was based, on how strong or weak was the ego, or how
strong or weak was the id impulse. In this revision, the only factor that symptom
formation seems to depend upon, is whether or not anger is repressed – and
always in relation to a who.
If the anger is indeed repressed, the result will necessarily be an acting out (or
acting-in), in the form of the development of a symptom. Since, it is proposed that
general hostile acting out may likely have been the first symptom of human his-
tory, then it may be possible to trace this dimension of hostility to the present,
where rather than exhibiting generalized hostility, evolutionary development has
enabled such acting out to crystallize in the form of the appearance of a matrix or
gradient of differentiated symptoms; in the case of the soldier, an anxiety symp-
tom. This gradient of differentiated symptoms is now in such profusion that to be
parsimonious in understanding them entire categories of symptoms have been
conceived. These include phobias, obsessions, compulsions, intrusive thoughts,
and so forth, as well as more overarching distinctions presented here – namely
accessible and inaccessible symptoms.
Summary
In this chapter, the repression of anger was examined and said to be the linchpin
of all psychological symptomatology. Further, with respect to the mechanics of
symptom formation, a proposed revision of traditional psychoanalytic under-
standing of symptoms and their formation was suggested, in which, from the
point of view of curing symptoms, considerations of psychosexual historical
material and sexual impulses were relegated to a secondary position, although
sustained in importance with respect to the psychoanalytic treatment process. In
contrast, from the point of view of the mechanics of symptom formation, as well
as the cure of symptoms, anger and its repression, in relation to the wish and the
who–the object–were elevated as the basic and sole variables accounting for such
symptom phenomena.
In the following chapter, the difference between symptoms that can be cured by
the talking method and through the use of the symptom-code will be discussed, in
contrast to those symptoms that resist such treatment and seemingly nullify the
effectiveness of the symptom-code. The issue of what makes this difference will
be considered.
Chapter 22
Symptoms Versus Character
Traits: Accessible Versus
Inaccessible Symptoms
It has been proposed in this volume that, with respect to psychotherapy treatment,
symptoms can be classified as either accessible or inaccessible. What this essen-
tially means is that there are some symptoms (the inaccessible symptoms), that
resist cure through psychotherapy, while other symptoms (the accessible symp-
toms), that indeed, can be cured through psychotherapy.
Further, it has been proposed that those intractable inaccessible symptoms,
those that are not responsive to the power of the symptom-code, actually join the
patient’s repertoire of character traits, and in effect, those symptoms then operate
in the personality as though they were character traits. Assuming the truth of this
ostensible and proposed phenomenon, then of course, application of the symptom-
code to these inaccessible symptoms would not, strictly speaking, be addressing a
symptom. It would be as if one were treating a malady that started out as a com-
mon cold but developed into a sinus infection, thereby perhaps and in all likeli-
hood, requiring a different order of treatment.
It is proposed that there are symptoms that start out as symptoms, but are then
subject to the vicissitudes of some yet unknown process or phenomenon of the
psyche, so that the symptom becomes translated into a character trait, or becomes
integrated into the character structure and then behaves as a trait, or is knitted into
the character structure, as it were, minus any ego-alien tension regarding its pres-
ence. Under this sort of condition, such a symptom presumably loses its symptom
context insofar as it no longer addresses issues solely regarding satisfaction of the
wish. Rather, it is proposed, the symptom remains as an idiosyncratic symptom
presence, but assumes another hue within the personality – that of a trait.
Therefore, it misses the point to treat such a symptom with psychotherapy that
targets cause and effect relationships, ties the symptom to the memory of a
repressed emotion in relation to an object, a person. Thus, applying the symptom-
code to such a translated symptom, no less a code that uses the same metapsycho-
logical notion of direct cause and effect between the repressed emotion and the
object, is also to miss the point. In contrast, to treat a symptom that has been
converted into a trait would all be well and good provided that the symptom as
character trait could be reconstituted as, strictly speaking, a symptom. Then, psy-
chotherapy and the application of the symptom-code could be a powerful tool in
149
150 22. Symptoms Versus Character Traits
helping the patient to more efficiently cure the symptom. But treating an
intractable symptom in this way, as though it exists within a typical symptom
context, is perhaps a failure to understand that: (1) the symptom is no longer
merely a symptom; (2) there needs to be a clear understanding of the difference
between symptom and character trait; (3) the symptom in the psyche has been
converted into a character trait and needs to be reconstituted as, strictly speaking,
a symptom, and only then treated as a symptom; and, (4) the treatment then
should consider targeting the psychology of character trait structure, in addition
to that of symptom structure.
What, Why, Who, When, Where, and How What Happens?

What Happens?
The question is, What happens to the symptom that transforms it into a character
trait? The answer is a tentative one based entirely on theoretical guesses, educated
though they may be. The important point seems to be that it is probably the case
that when the anger is repressed (and repressed toward the who, that is, with
respect to the memory of the who) then the symptom remains a symptom, and
would be definitely subject to the application of the symptom-code as it can be
utilized in the therapy. However, the assumption is now made that in the psyche
unconscious forces operate in a number of ways so that it is possible, under cer-
tain circumstances, for the memory of the who, to be detached or delinked from
the repression of the anger. In such a scenario, the anger remains repressed with-
out a who toward whom this anger was originally attached. The memory of the
who is now shifted away from the repressed anger and this anger is left perhaps
aimless, having no memory of an object.
It should be remembered that one of the axioms upon which the symptom-code is
based concerns one of the immutable laws of emotion; that is, that an emotion is only
realized as an emotion when it takes an object. What this means is that the emotion
(in this case, anger that is repressed), is only completed as an emotion when it
attaches to its intended person, its object. In this way, as a result of the attachment to
a new object, the repressed anger can then fulfill its role – be an emotion.
However, this search becomes perseverative because when the memory of the
who becomes detached from the repressed anger, and therefore, the nature of
the symptom becomes altered, then this search for the object is unproductive
because the goal can never be met; the goal being a discovery and reattachment
of the memory of the original object to the repressed anger. Yet, if only to feel
satisfied, this tropistic search continues. In such a scenario, because the memory
of the original object is erased, then the model for any true transference figure to
exist, is also just about entirely absent. It would be an emotion trying to
complete itself but not knowing why or even how.
This endless search of a who by the repressed anger, means that such a symp-
tom will resist all attempts to be reached. The symptom becomes a moving target,
all of its energy being consumed by this never-ending search for something,
Why Does it Happen? 151
perhaps the true who. Instead, the question becomes: Does finding a surrogate
who (a transferential figure or figures) ever satisfy the emotion (the anger) in any
real sense? This is what may determine why the symptom becomes intractable,
inaccessible. It is a generalized repetition compulsion acted out by mechanisms
of the psyche that produce perseverative psychological impulses. The need such
mechanisms serve concerns attempts to master the original problem of reigniting
the memory, reattaching the object to the repressed anger. Thus, it would seem
that when the repressed anger remains attached to its target object, the who, then
the symptom is retained in the psyche as an encapsulated one. In such a case, the
symptom is not part of the person’s character trait context, but rather remains
within the domain of the psyche concerned with wishes. In this sense then, the
symptom that remains apart from the character trait context would be considered
the class of symptom accessible to psychotherapy and indeed, could be cured by
applying the symptom-code.
Why Does it Happen?

As stated above when, in the psyche the who or the memory of the who becomes
detached from the repressed anger, then this anger remains without an object. This
may mean that the emotion, the anger, will need to find another object with whom
to bond or become attached. The basic question, however, is: Why does the memory
of the who detach from the anger? The answer could possibly involve the infrastruc-
ture of the anger itself, as in a cumulative sense it impacts the psyche. Simply put,
the anger can be overpowering with respect to the integrity or viability of the psy-
che. In its pure repressed form that fuels the stasis of the symptom, the anger may
become too much for the psyche to handle. This kind of anger then, may threaten
the very cohesion of the psyche so that under such a condition, an immediate imper-
ative of the psyche would dictate the evocation of a process to relieve this sort of
threat to its existence. And of course, such a threat can also result when one’s ego is
configured with a so-called, thin stimulus-barrier. What this means is that there are
individuals who are not resilient enough to withstand the intensity of certain emo-
tions – especially anger, or its higher intensity of fury or rage. And this sort of less
than resilient ego does not necessarily imply the thin stimulus-barrier of the border-
line diagnosis, primarily because borderline reactions are usually characterized by
episodic eruptions of anger, rather than by episodic repressions of anger.
Thus, to answer the question of why the symptom transforms into a trait, an
analysis of the structure, valences, and nature of each particular anger needs to be
identified, even enumerated, and of course, analyzed. It is here proposed that in a
basic sense these constituents of the anger would include the factors of magni-
tude, intensity, depth, and duration of the anger. In concert, and at high levels of
activation, these factors of magnitude, intensity, depth, and duration of the anger,
will most likely create the signal for the psyche to begin the process of transport-
ing the symptom out of the domain in the psyche devoted to the gratification of
wishes, and into the domain or realm in the psyche of character trait structure.
It is the magnitude, intensity, depth, and duration of the anger that needs to be
examined in order to understand why the memory of the who detaches from the
anger. These seem to be the essential factors of the anger, its infrastructure, that
give it its final form.
Magnitude of the Anger

In examining the anger, it could be asked: What was the magnitude of this anger?;
that is, how much of the psyche did it cover, or radiate? All of it? Most of it?
Some of it? Hardly any of it?
Given an intact ego, the point is that the more of the psyche this anger affects or
radiates, the greater the possibility that the connection of the memory of the who,
will be severed from the repressed anger. The corollary is also a possibility; that
is, the less radiated the psyche is by such anger, the less probability there may be
of a disconnection between the memory of the who and the repressed anger.
Intensity of the Anger

How shrill is the anger? How intense was it? How dense was its implosive power?
Another piece to the puzzle of what happens to cause the memory of the who to
become detached from the repressed anger is thus offered a companion factor.
If the implosive power of the anger was great, then the probability increases that
the disconnection between the memory of the who and the anger, increases. But if
the implosive power of the anger was not great, then the probability of the
connection between the memory of the who and anger, more likely would be
sustained.
Of course, were the magnitude of the anger to have permeated all or most of the
psyche, and along with this, the intensity or implosive power of the anger also was
great, then the probability of the detachment between the repressed anger and the
memory of the who would be predictably increased.
Depth of the Anger

How deep is the anger, how far does it penetrate to the core of the psyche?
It would be predicted that the deeper it goes, the greater is the possibility that the
memory of the who will be disconnected from the repressed anger. In this sense,
such a disconnection would then contribute to the greater inaccessibility of the
symptom to normal psychotherapy through the use of the symptom-code.
Of course, the resilience of a person’s ego now also comes into play. With a
stronger ego, even intense anger could have a more difficult time penetrating
deeply into the psyche. In this sense, a better ego is a better shock absorber.
With a magnitude of anger covering most or all of the psyche, and with a great
intensity in the implosive power of the anger, along with an extensive penetration
of anger to the core of the psyche, reflecting either a maximum or near maximum
depth of penetration, it would be predicted that the symptom would in all likeli-
hood be even more predictably inaccessible to psychotherapy. This would be true
Where Does it Happen? 153
because under these conditions of the vicissitudes and nature of the repressed
anger, the vast probability is that, in the alliance of all of these infrastructural fac-
tors to the anger, the detachment of the memory of the who from the anger that is
repressed, would be more definite.
Duration of the Anger

Finally, the fourth infrastructural dimension in the formation of a process that
pries loose the memory of the who from the anger, or another significant factor
that can contribute to such a detachment, and thereby promote the transport of
the symptom from the psyche’s domain of wishes into its realm of character
traits, is the variable of duration. How long has it been since the patient began
experiencing the symptom? At a certain point in its duration a symptom, rather
than being considered an acute phenomenon, becomes a chronic one. It is this
historical or temporal dimension that distinguishes between acute and chronic
symptoms.
Along with duration of the anger, the variables of magnitude, intensity, and
depth, as a full complement of variables, can cause a change in any critical
threshold that ignites the need for the psyche to delink the memory of the who
from the repressed anger, thereby evoking the migratory process that sends the
symptom from the domain of wishes to the domain of traits. When such a criti-
cal threshold is not reached, the symptom would remain in a state that still may
be treated by way of the symptom-code. This is in contrast to a symptom where
the magnitude, intensity, depth, and duration of the repressed anger is great,
thereby suggesting that the symptom has become inaccessible to therapy, and
along with its symptom configuration has acquired membership in the character
trait context.
These then, it is proposed, are the factors that distinguish between symptoms
that are accessible to treatment with the symptom-code, and those that are not
treatable with such a code. Rather, the inaccessible symptoms would require a
character-code to cure, because basically, although they are still symptoms, they
are no longer solely symptoms.
Thus, to treat this new form, a symptom that is visible as a symptom, but has
become a trait, requires an understanding of the structure of character formation
along with character defenses, and should not rely solely on an understanding of
the formation of psychological/emotional symptoms proper.
Where Does it Happen?

Where does the symptom do its migrating from the domain of wishes to the
domain of traits? The hypothesis is that it happens in the psyche, an abstraction. To
visualize the psyche is to utilize whatever heuristic device that seems useful. This
could be an amalgam of models, or even a single structural one. For example, the
psyche can be seen structurally as an orb, or conceived as an amalgam of Freudian
models such as intrapsychic, structural, topographical, psychosexual, genetic,

adaptive, and economic, or as the mind-organ that coheres it all, personality,
cognition, emotion, motivation, into some syndromal synthesis. Even in visualiz-
ing the psyche, it may be conceived that the psyche is constructed in at least three
dimensions, and that within this scope of such a metaphysical arena are various
domains of personality, including emotions, drives, wishes, defenses, cognition,
motivation, attitudes, and so forth, all dynamically related and ultimately governed
by psychoevolutionary and epigenetic structural rules. Whatever it is that happens,
is considered here to happen in the psyche, this abstraction that lends itself to any
number of visualizations and conceptualizations.
When Does it Happen?

If the transformation or shift of the symptom to the realm of character traits
does take place, it would occur rather quickly, and over time would become
integrated into the repertoire of character traits so that the symptom would
become part of that person’s personality print. “Rather quickly,” does not neces-
sarily mean instantly. The experience of the symptom, underpinned by repres-
sion of anger, and accompanied by a wish, would, always appear as a symptom
and act like a symptom, no matter its location in the psyche. When the migra-
tion occurs, however, would depend upon the magnitude, intensity, depth, and
duration of the anger. When these factors are great, then the psyche would pos-
sibly experience a “psyche-quake,” so much so, that an implicit imperative
regarding the survival of the psyche would, in all likelihood dictate, even man-
date some process to deliver this symptom out of the domain of wishes in the
psyche and into the fabric of the personality. Perhaps the only place the symp-
tom would be able to go would be into the psyche’s realm of character traits.
This shift or transformation may become more and more cemented, based upon
elapsed time. Thus, it happens during the accrued duration of time that elapses
from the moment that the psyche experiences a challenge to its integrity, to the
time of the process whereby the psyche expels the symptom, either by shifting
it, transforming it, or both.
Who is the Who?

With respect to symptoms, the who is a reference to the object. Yet, there really
are two who’s. The standard who is the object of the patient’s anger. It was this
anger that could not be directly expressed to the object, and therefore needed to
be repressed. When the anger is repressed, the object becomes the subject, and
therefore, the anger attacks the self. In other words, the subject (the self)
becomes the surrogate for the original intended object of the anger, the other
person–the who. Thus, when the anger takes the self, in a way, then two who’s
exist.
How Does it All Happen? 155
How Does it All Happen?

Now that some theoretical attempt has been proposed with respect to the issue of
the psyche protecting itself from threat and challenge to its integrity, especially
with respect to the process that shifts the symptom to the domain of traits, the
question arises as to how it all happens. How does the psyche enable the symptom
to migrate out of the realm of wishes and into the realm of traits? One answer is
perhaps revealed in the discussion above on the what, why, who, where, and when
of the psyche. It has been proposed that the nature of the repressed anger can be
the motivating ingredient that forces the psyche to maintain its equilibrium.
Whenever tension becomes too much to handle, then the equilibrium of the psy-
che can be sustained probably only by the recalibration of the tension within its
boundaries. However, when this presumed increase of psychic tension becomes
threatening (perhaps a threat to the very existence of the person’s psychological
life in the form of the threatened viability and integrity of the psyche), then such
tension becomes an urgent alarm signal. In this sense the psyche is the central
salient agency of a person’s psychological existence.
Thus the question is again raised. How does the psyche manage to get the
symptom translated from the domain of wishes, to the domain of traits? It is
assumed that the initial tension within the psyche that motivates this migration,
results from the nature of the repressed anger. The memory of the who is detached
from the anger because the magnitude, intensity, depth, and duration of the anger
becomes too much for the psyche to handle. The migration takes place in the
abstraction we identify as the psyche. It takes place when the anger becomes too
large for the psyche to feel comfortable in its management.
At this point, when presumably the psyche experiences the need to extrude the
symptom from the realm of wishes, it is possible that it does so by the use of
defenses. Thus, it is proposed that how it happens is through the use of defense
mechanisms; that is, defense mechanisms can be utilized to incubate this transla-
tion of symptoms in the psyche’s domain of wishes into the psyche’s realm of
traits. Within the psyche’s domain of wishes, the symptom remains an accessible
one and can be efficiently addressed with the symptom-code in a process of cure
through psychotherapy. When, however, the symptom is processed through the
psyche, so that it ultimately metamorphoses at least into traitlike form (i.e.,
retaining also its symptomness) and into the realm of traits, then there are various
specific defense mechanisms that can be recruited by the psyche to accomplish
this process.
In the following chapter, these mechanism of defense will be delineated, and it
will be proposed that there exists a certain class of defenses that permit such a
transformation to take place, while other more usual defense mechanisms are not
at all suited for this kind of shifting of domains in the metapsychological arena of
the psyche.
Chapter 23
The Metamorphosis of Symptoms:
The Domain of Wishes
and the Domain of Traits
It is proposed, that in the psyche various mechanisms of defense are utilized in

the transformation and shift of the symptom from the domain of wishes to the
domain of character traits. Of course, psychoanalytically, all mechanisms of
defense are conceived as operating within the dynamic rules of the psyche, and by
the laws of the unconscious. Yet, in order to understand the hypothesized phe-
nomenon of this shift of symptom from a wish dominated encapsulated neurotic
state into a trait dominated character or characterological state, it would seem to
be necessary to distinguish between two kinds or classes of defense.
In conventional psychoanalytic theory, the defense system, originally gestates
with respect to the needs of the ego, and defenses are considered to be ego
defenses. Yet, it could be argued that defenses are artifacts of a psychoevolution-
ary process in which the vicissitudes of basic emotions created imperatives for
mechanisms to become active that could manage each of these emotions. In this
sense, defenses could also be considered emotion defenses. For example, the
defense of displacement could easily be understood as developing in evolution to
manage the basic emotion of anger. Similarly, the defense of compensation could
also be seen as having developed to address the issues of loss, inadequacy feel-
ings, sorrow, or even depression. Compensatory behavior as a reaction to loss, for
example, is an experience common to all people.
Further support to this idea of the birth and ontogony of defense as inextricably
related to the needs of emotion, is perhaps revealed by the plasticity of the entire
defense system; that is, the defense system as well as individual defenses,
although perhaps developed to address the needs of specific emotions, are also
very well adapted, so that particular defenses can be utilized to manage any other
number of emotions, either as individual defenses or in defense clusters. For
example, the management of obsessional states can enlist a cluster of defenses
that include not only intellectualization, but also rationalization, sublimation,
undoing, and isolation. This adaptational plasticity of the defense system can
explain therefore, why in evolution, this system was highly selected (Kellerman,
1980; Plutchik, 1980).
Actually, considerable theoretical as well as empirical studies have been published
with specific reference to this sort of understanding, as well as providing a general
157
158 23. The Metamorphosis of Symptoms
theoretical underpinning to the notion of defenses as emotion derived (Kellerman,

1979, 1980, 1983, 1987; Kellerman & Burry, 1997; Plutchik, 1980, 1994).
Also, any sole defense mechanism is called upon in its daily duty, to manage the
basic structural constituents of emotion; that is, to manage the transitory nature of
emotion. This transitory characteristic of emotion can be seen in the ebb and flow
of everyday life where emotions are instantly experienced, are modified, changed,
and frequently otherwise fleeting. It is also probably true that these typical emo-
tion defenses, or as they are more typically referred to, as ego defenses—including
repression, compensation, denial, displacement, intellectualization, isolation,
projection, rationalization, regression, sublimation, undoing, and so forth–are also
utilized in the fortification and cementing of character traits. An important point to
note, however, is that such defenses are proposed as quite secondary in their use as
significant factors in the formation of such character traits.
Rather than these so-called emotion defenses being essentially responsible for
the formation and cementing of such character traits, another class of defense
appears as actually the more corresponding mechanisms of these character-trait
formations. This other class of defenses may be called character defenses, and are
different in definition as well as function, than are the emotion defenses referred
to above.
The character defenses have not developed to manage transitory states such as
the basic emotions or even to manage more subtle mixed emotions. These charac-
ter defenses are products of the psyche that synthesize the presumed compro-
mises of instinctual drives with the demands of reality. The character defenses
then, help to create establishments of reflexive, automatic patterns of behavior or
traits, which when cemented as trait organizations, or trait clusters, or personality
trait profiles, come to exist in more permanent arrangements, as more permanent
etchings of the personality. These character defenses then, bind impulses and
create each person’s more permanent or consistent personality print.
The Class of Character Defenses

As emotion defenses (or ego defenses) manage emotion (mostly with respect to
the transitory nature of emotion), character defenses, as stated, are utilized by the
psyche to arrange, organize, and hold in place, more permanent fixtures of
the personality–the traits. These character defenses therefore, are instrumental in
the formation of enduring personality-trait patterns. This explication of character
defenses as they stand in contrast to so-called emotion defenses, is examined fur-
ther by Kellerman (1987), and Kellerman and Burry (1997).
The amalgam of character-defenses include:
Identification
This character defense is to character traits what repression is to emotion.
Identification is a ubiquitous phenomenon that occurs axiomatically. It is the
common underlying element in the development of trait patterns and acts to
The Class of Character Defenses 159
create reflexive, automatic, non-anxious behavior in the subject. Identification

acts as a control over whatever configuration of personality finally forms.
Internalization
This character defense absorbs or infuses values and attitudes from model objects
or figures, and imprints them so that such values and attitudes can ultimately pre-
vail over the press of other external influences on the personality.
Splitting
This character defense enables self-contained compartmentalizations to exist in
the psyche. Thus, splitting prevents the ambiguity that would ordinarily be asso-
ciated with conflict. Individuals can be divided into good and bad objects, and
idealizations as well as devaluations can be directed to the same person, rendering
contradictions insignificant.
Turning Against the Self

This character defense enables hostility that is relatively intolerable, to shift from
the object to the self. Thus, despite an increase of internal complexity, the subject
is then able to more easily tolerate particular external conflict or pressures.
Symbolization
This character defense enables wishes, fantasies, and impulses, to become dis-
guised through internal or external representations. Freud first indicated that it is
the capacity for symbolization that largely determines, and underlies, the basis of
character structure. Josephs (1992), elaborates and points out that Freud came to
this conclusion by seeing that the essence of symbolization in the development
of character traits concerns the notion of the unacceptable idea, impulse, emotion,
or attitude, needing to find a place to reside. The answer was that the symbolic is
connected to the unconscious because of the unacceptable idea. Actually, in
conventional psychoanalytic understanding, symbolization permits an indirect or
substitute satisfaction of the wishes. Freud regarded these wishes as unacceptable.
In the theoretical formulation proposed here, however, it is assumed that sym-
bolization permits gratification of wishes to occur, but not merely with respect to
unacceptable wishes. Rather, symbolization can indeed permit gratification of
unacceptable as well as thwarted wishes which may not be unacceptable, but
which may have become thwarted because of a possible variety of other reasons,
all however, related to the connection of self-interest, survival, and fear.
The idea of symbolization is crucial to the understanding of several important
seeming conundrums. For example, Freud’s ingenious discovery that every symp-
tom reflects and represents a particular wish in a completely gratified way, albeit
in neurotic form, meant that the wish was symbolized in the symptom, and as the
symptom. This insight also permitted Freud to understand that because the symp-
tom represents the gratified wish, then everyone loves their symptoms (whether
they know it or not), even those that are painful, because these symptoms are
really the wishes, gratified.
The idea that character formation is in part, based on the capacity for symbol-
ization, also has great currency in contributing to the understanding of why the
wish joins the anger in repression. The symbol contains the essence of the wish
and is sustained, fueled by the repressed anger. Also, when anger cannot be
directly expressed to its intended object, it becomes instantly repressed, so much
so, that the subject is not aware of the anger ever having even existed. Then, when
the anger, alloyed with the wish is repressed, a symptom will necessarily appear.
The rules governing such a connection between repressed anger and the appear-
ance of a symptom are based on theoretical insights presented throughout this
volume.
Parenthetically, such insights represent a clear departure from traditional
Freudian understanding that a symptom is, strictly speaking, derived from some
childhood sexual trauma and that because of the failure of repression in adult life,
infantile sexual impulses find their release and end up causing symptoms. The
departure here is based on the notion that symptoms only derive from repressed
anger against a who someone who has thwarted a wish, and is not at all a function
of some infantile sexual disturbance. In fact, it is proposed that the only way
infantile sexuality can contribute to the formation of symptoms, concerns the
thwarting of a sexual wish–at any time during development, including, but not
necessarily solely during childhood–and because of this thwarting of the sexual
wish, the subject (whether child or adult) becomes angry, and cannot, because of
any number of factors (especially those factors of survival), express this anger
directly to the object. Then, the anger, and not the sexuality, is repressed.
The Wish and the Anger

With respect to character formation and symbolization, it is still necessary to set
forth how and why the wish joins the anger in the repression. The answer may be
approached by examining how the anger “understands” what the thwarted wish
was. Since the symptom reflects the thwarted wish, then this also may mean that
the anger understood that the wish was thwarted, or, more importantly, what that
wish was.
The question then arises, whether anger, as a basic drive or emotion with a pre-
sumed unidimensional personality (to attack) also, and perhaps surprisingly, has a
cognitive component to its nature as well. Can the anger know something, in this
case about the wish? According to Freud, the answer would not be in the affirma-
tive. The answer would not be that the anger understands the wish as though some
communicational interaction between them exists. Rather, it seems that a hard
core Freudian proposition would predict that it is the symbolization of the wish
that accompanies the anger, via repression, into the unconscious, and not that the
anger is intelligent, above and beyond what is here considered its attack impera-
tive, its basic nature.
Of course, a hypothesis can be entertained that suggests the possibility that per-
haps the anger (or for that matter any other basic emotion) does in fact, possess
The Migration of Symptoms in the Psyche 161
cognitive capacity, especially, or even perhaps only, with respect to symboliza-

tion. That is, that perhaps anger, or any other basic emotion actually “under-
stands” symbolization or “understands” the valence of the symbol as it represents
wishes. This possibility raises some interesting implications regarding the psy-
chology, and even perhaps, the morphology of basic emotions, in this case, anger.
However, it seems far more likely that the psyche arranges for the possibility of
the anger to be repressed, while simultaneously capturing the essence of the wish
in symbolic form, and attaching it to the anger; that is, in its split-second repres-
sion, the psyche attaches in symbolic form, the message of the wish, to the anger.
Thus, the anger and the essence of the wish are repressed together, and through
the process of repression, as well as for the reason of the repression, become
attached. They then coexist in the psyche’s domain of wishes. In this sense, the
basic emotion (in this case, anger), retains its unidimensionality. Therefore,
the possibility of a cognitive capacity to basic emotions seems theoretically
undermined.
In addition, when, in the unconscious, the anger, and the memory of the who
also remain attached, they then form an alliance, ultimately with symbolization
comprising the symptom that occupies the wish domain of the psyche, the realm
in which neurotic symptoms exist. It is these symptoms that are subject to cure
through the use of the symptom-code and via psychotherapy, presented in Part II
of this volume, “Accessible Symptoms.”
The Migration of Symptoms in the Psyche

The psyche’s domain of wishes is not the same as the psyche’s domain of traits.
In the domain of traits, it is proposed that symptoms may be part of this trait
domain or realm, but as such, they may not be composed of a memory of the who,
as fused with or attached to the repressed anger. Traits are configurations formed
out of the mechanisms of identification, internalization, splitting, turning against
the self, and symbolization. These are unconscious mechanisms of the psyche and
therefore memory of a who is anathema to this trait region of the psyche.
The key point in the shift or metamorphosis or migration of the symptom from
the domain of wishes to that of traits, is the proposed phenomenon of the
repressed anger becoming detached from the memory of the who. This proposed
delinking then ostensibly permits a migration of the symptom out of the psyche’s
domain of wishes, and into the psyche’s realm of traits. Under this new condition
of the symptom having been transformed (migrated, or metamorphosed) to the
realm of traits, the symptom’s inner imperative is changed, so that no longer can
it be cured through use of the symptom-code. Now, the symptom needs a new
approach, a symptom/trait-code. And as is well known, treatment of character
structure is far more complex and difficult than treatment of a neurotic symptom
state. At least in the neurotic symptom state, anxiety acts as a signal and even
motivator for change, and the symptom remains ego-alien and apart from the per-
sonality trait structure. With character problems, however, the symptom as a trait
presumably suffers from an absence of the signal of anxiety acting to motivate or

induce change.
Thus, as a symptom in the domain of wishes, the wish is gratified in perverse or
neurotic form and therefore we love our symptoms. Yet, they cause us difficulty,
anxiety, embarrassment, and so forth, so from a practical vantage point, we also
hate them. However, when because of the separation of the memory of the who
from the repressed anger, the symptom then migrates to the domain of traits and
no longer acts with tension and anxiety about itself.
This discussion has been concerned with identifying a basic distinction
between a neurotic symptom and a character trait, and has provided a tentative
answer to possibly illuminate why some symptoms resist change while others can
be cured quite efficiently. Of course, according to this view of treatment, those
symptoms that resist change and are relatively inaccessible to cure, have become
trait symptoms and in the psyche correspond to the realm of traits. In contrast,
those symptoms that are deemed here to be accessible to cure, are those symp-
toms that reside in the psyche, in the realm of wishes.
Summary
In this volume, the theoretical framework of the traditional view of symptoms,
and their formation and treatment has been contrasted with an alternative under-
standing. In this alternative understanding, accessible symptoms, those that, it is
claimed, can be cured through the symptom-code that is presented, and via the
psychotherapeutic method, have been contrasted with inaccessible ones, those
symptoms that resist change and are thought to require a different code, one con-
cerned with the penetration of character traits and character structure.
Furthermore, an important difference in the fundamental understanding of
symptoms has been asserted. Rather than seeing infantile sexuality as the crux
of the matter in symptom formation, the theory proposed here, points to the
basic or nuclear factor of all symptom formation as a process beginning with a
thwarted wish and ending with the symbolization of that wish as associated
with repressed anger. This repressed anger is fused with the memory of the
who–the person or object toward whom the anger was initially directed but
toward whom it could not be expressed.
The salient psychoanalytic shift here is from sexuality to anger. Of course, both
drives of sexuality and anger satisfy the pleasure principle. Both are empowering
insofar as both satisfy needs. But whether sexuality becomes repressed, or
whether it is really anger about thwarted sexuality or about any other thwarted
wish that becomes repressed, is the essential issue.
The answer, although tentative, nevertheless seems to have profound implica-
tions in understanding a variety of issues within the arena of the psychoanalytic
discussion. The core shift of focus is that it is anger and not sexuality that
becomes repressed and therefore, that anger is the salient variable in symptom
formation. Anger now becomes the focus. Repressed anger produces symptoms,
Coda 163
while the repression of sexuality in relation to symptoms, in this particular theo-

retical framework, is not very relevant. Thus, it cannot be the use of a symptom
code containing basic terms of repressed sexuality, identification of the who, and
consciousness of the wish, that will cure symptoms. Rather, only a code that uti-
lizes terms of identification of the who, with consciousness of the wish, and most
importantly, with a focus on repression of anger toward the who, that can ever
cure the symptom.
Assuming the veracity of this challenge then the next step is the development
of a trait-code that can address those inaccessible symptoms that resist cure, that
because of the delinking of the memory of the who, with that of the repressed
anger, have become symptoms as traits, and therefore do not exhibit the typical
characteristics of neurotic symptoms. In contrast, the neurotic symptoms exist as
encapsulations set apart from the character structure and contain palpable signal
anxiety regarding the presence of such symptoms.
In the psychoanalysis of symptoms therefore: (1) repressed anger; (2) fused
with a memory of the who toward whom the original anger was directed; (3) in
conjunction with the symbolization of the wish, all reside in the domain of the
psyche devoted to wishes; and (4) together with a consequent addendum to the
symptom-code of a doing activity related to the original wish, comprise the symp-
tom-code that enables the subject to move from a behind The Line withdrawal
state, to an in front of The Line “doing” state.
Thus, it has been proposed throughout this volume that these four factors in the
dynamic of the psyche, represent the essence of the symptom-code, which when
applied to the treatment of symptoms that exist in the psyche’s domain of wishes,
can efficiently lead to the cure of the symptom.
Coda
A new, although related theme emerges in relation to the entire consideration of
symptom psychology. That is, that to further understand the genesis of symptoms,
it may just be that symptoms involve a cluster of concerns that combined, consti-
tute a syndrome common to all people. This syndrome may be identified as one
containing thematic strands of separation anxiety, dependency, sorrow, depression,
abandonment, and loss. This syndrome may be labeled “attachment/separation.”
Thus, it may be that every symptom has as its fundamental reason for being, some-
thing connected with the broad issue of attachment/separation. In other words,
with respect to psychoanalytic drive theory, the ubiquitous reflex of anger (in this
case with reference to feelings of disempowerment), is likely to be animated by an
epigenetic trigger. And this epigenetic trigger – this environmental stimulus that
ignites the process that ultimately leads to symptom formation, always may be
based upon an attachment/separation theme.
In a future evolution of the symptom-code addressing both accessible as well
as inaccessible symptoms, the theme of attachment/separation may contribute to
a general synthesis. The reader is invited to consider this proposition related to
the theme of attachment/separation with each symptom that has been presented in
this volume.
Taken as a whole however, the symptom-code presented here has generated a
system of propositions, assumptions, and axioms, that congeal an array of phe-
nomena, sufficient perhaps, to qualify as a body of work, to this point identified
as: The Psychoanalysis of Symptoms.
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Index
Acting out, psychoanalytic understanding Clinical case studies, of accessible symptoms

of, 4, 143–144 agoraphobia, 71–76
as first symptom in evolution, 141 body delusion, 37–38
Agoraphobia, case of compulsion behavior, 31–32
application of symptom-code, 72–74 displaced phallic obsession, 83–88
case background, 71 feeling of migraine, 77–81
initial consultation, 71–72 hallucination thoughts, 67
symptom analysis and findings, 74–76 morbid compulsion, 55
of 60-year-old woman, 107–110 nighttime sweats, 46–47
Anger, 142 obsession thoughts, 59–62
and sex, 141 obsessive thoughts of death, 49–50
Anger, experience and management of, 14–18 thoughts of strangling, 43–44
duration, 153 Clinical case studies, of inaccessible symptoms
intensity, 152 agoraphobia, 107–110
magnitude, 152 anorexia, 115–120
and wish, 160–161 blushing, 91–99
Anorectic symptom, 11s8–120 delusional self-incrimination, 101–105
Anorexia, case of dissociative identity disorder, 121–125
application of symptom-code, 117–118 Nash, John Forbes Jr., 127–137
case background, 115–117 obsessive-compulsion disorder, 111–114
Anxiety, issue of, 6–7 Compulsion behavior, case study on
Asperger’s syndrome, case of, see Nash, application of symptom-code, 32–34
John Forbes Jr. initial consultation, 31–32
symptom, development of, 32–34
Basic emotions, 17 Constant terms, idea of, 8
Blushing, cases of Conversion process, 7–8
symptom-code and infrastructure of, 92–93
28-year-old physician, 97–98 Death instinct, notion of, 9–10
40-year-old librarian, 95–97 Defense equilibrium, 5
70-year-old businessman, 93–95 Delusional self-incrimination, case of
Body delusion, case of application of symptom-code, 103–105
analysis, 41–42 case background, 101–103
application of symptom-code, 38–40 Disempowerment, issue of, 13–14
initial consultation, 37–38 Displaced phallic obsession, case of
Brenner, C., 5–6 analysis and findings, 87–88
application of symptom-code, 86–87
Character defenses, 158 case background, 83–84
Character trait and symptoms, 149–155 initial consultation, 84–85
167
168 Index
Dissociative identity disorder Morbid compulsion, case of

application of symptom-code, 124–125 analysis and findings, 58
case background, 121–122 application of symptom-code, 57
background, 55
Ego-alien reaction, 11, 149 initial consultation, 56–57
Ego defenses, see Emotion defenses
Emotion defenses, 158–160 Nash, John Forbes Jr.
Engel, G., 7 application of symptom-code, 134–136
diagnosis of Asperger’s syndrome, 128
Fenichel, O., 7 elements of Nash’s problem, 130–134
Ferenczi, S., 8 first schizophrenic episode, 130
Freud, S., 24 treatment, 136–137
amalgam of variables on study of symptoms, 3 Nighttime sweats, case analysis of
conversion process, 7–8 analysis and findings, 49
development of symptoms, 4 application of symptom-code, 48–49
hysteria, 4 case background, 46–47
issue of anxiety, 6 initial consultation, 47–48
relationship between wish and symptom, 4–5
repression, concept of, 4 Obsession thoughts, case of
wish, concept of, 5–6, 8 analysis and findings, 64–66
application of symptom-code, 63–64
“Giving-up/given-up” complex, 7 initial consultation, 59–62
Obsessive-compulsion disorder, case of
Hallucination thoughts, case of application of symptom-code, 113–114
analysis and findings, 69–70 case background, 111–112
application of symptom-code, 68–69 Obsessive thoughts of death, case of
case background, 67 analysis and findings, 52–53
initial consultation, 68 application of symptom-code, 51–52
Helplessness, 13–14 background, 49–50
History, of psychological symptoms initial consultation, 50–51
constant terms, idea of, 8
conversion process, 7–8 Phases, of emotional-psychological
defense equilibrium, 5 symptoms
development of symptoms, 4 issue of emotions and objects, 22
issue of anxiety, 6–7 pleasure principle of life, 19
repression of anger, 19–21
Identification, 158–159 symptom formation, 22–23
Inaccessible symptoms, 149 Positive/negative symptoms, 25
Internalization, 159
Involuntary reaction, 11 Rangell, L., 16
Repression, concept of, 4, 7, 13–14
Kellerman, H., 17
Schmale, A., 7
Learned helplessness, 7 Sex/anger, 141
Line, notion of, 27–28 Splitting, 159
Luborsky, L., 8, 10 Symbolization, 159–160
Symptom code
Migraine, case of acting out, psychoanalytic understanding
analysis and findings, 80–81 of, 143–144
application of symptom-code, 79 anger, experience and management
case background, 77 of, 14–18
initial consultation, 78–79 applications, 19–24
Momentary forgetting, 8 axiom of, 142
Index 169
on basic emotions, 17 Luborsky, L., 8

clinical cases, 145–147 Schmale, A., 7
definition of a symptom, 10–12, 23–24 Seligman, M., 7
disempowerment and helplessness, 13–14 Thoughts of strangling, case analysis of
migration of symptoms in psyche, 161–162 analysis and findings, 45–46
primacy of anger, 142–143 application of symptom-code, 44–45
role of sexuality, 144–145 case background, 43–44
symptom formation, psychoanalytic initial consultation, 44
understanding of, 144–145 Transient symptoms, 8
themes, 9–10 Tyrannical reaction, 11
wish, concept of, 12–13
“Who” The, 22
Theoretical works, of psychological symptom Wish, concept of, 5–6, 8, 12–13
Brenner, C., 5–6 and anger, 160–161
Engel, G., 7 relationship with symptom, 4–5, 25–26
Fenichel, O., 7 Withdrawal state and symptom, 26–27
Ferenczi, S., 8 line, notion of, 27–28
Freud, S., 3–5, 7–8

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The Psychoanalysis of Symptoms

Henry Kellerman, Ph.D.

ISBN: 978-0-387-72247-4 e-ISBN: 978-0-387-72248-1

Library of Congress Control Number: 2007929735

© 2008 Springer Science⫹Business Media, LLC

Printed on acid-free paper.

Organization of the Volume

penetrated or erased through the application of the symptom-code and psychother-

4. A presentation of theoretical issues detailing the outlines of the entire symptom

Part I: Theoretical Context . . . . . . . . . . . . . . . . . . . . . . 1

The Symptom and the State of Withdrawal . . . . . . . . . . . . . . . . . 26

Part II: The Clinical Casebook:

11. Panic on the Bridge: A Case of Selective Agoraphobia . . . . . . . . . . 71

Part III: The Clinical Casebook:

20. An Asperger’s Mind: An Examination of the Case of Nobelian

Part IV: Examining Theoretical Issues

The history of psychological symptom formation as a clinical and scientific sub-

Thus, in Freud’s amalgam of variables bearing on the appearance of symptoms,

Case of Hysteria” (1905/1953), he indicated that in the process of the solution to

Repression and the Hint of a Key Emotion

The Idea of Constant Terms

Defining the Symptom

the symptom, need to be considered in order to develop a complete picture of the

To continue with this image of pathological debris infiltrating and permeating

The Gratified Wish Means Empowerment

more intense and will, in all probability, be generated as rage or fury–sometimes

repression is able to redirect the instinctual impulse thus neutralizing threat of

On the Nature of Basic Emotions

How is Anger Managed?

when a person experiencing a thwarted wish feels disempowered, and then as a

In the understanding of this system of assumptions, propositions and axioms

Phase 1: Before the Symptom Forms

Phase 2: Formation of the Symptom

Phase 3: The All Important Who

Phase 4: The Lifting of the Symptom

A final coda relates to chronic, resistive, deeply etched, or engraved

Definition of a Symptom: Infrastructure

Positive Versus Negative Symptoms

The Wish and its Relation to Ameliorating

The Symptom and the State of Withdrawal

Withdrawal is transferential insofar as the person in withdrawal can think,

Accessible symptoms are those that:

The Initial Consultation

Applying the Symptom-Code

Understanding the Symptom

An elderly man of 80 was committed to a city hospital facility for observation.

The Initial Consultation

Applying the Symptom-Code

Understanding the Symptom

A Case of Intrusive Thoughts of Strangling

The Initial Consultation

Applying the Symptom-Code

Understanding the Symptom

A Case of Nighttime Sweats

The Initial Consultation

Applying the Symptom-Code

Understanding the Symptom

A Case of Obsessive Thoughts of Death