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A Patient Who Suffered Alternately from Colitis and Migraine 149

the analyst did not let himself be swayed by this. He persisted steadfastly in an endless, patient repetition of the same questions, over and over again. With every opportunity that presented itself he asked her how it came about, with such a countless diversity of creatures in the world, that precisely snakes and worms, of all things, came and intruded themselves upon her in this way. And since they did come, why couldn't she have a better relationship to them, why couldn't she manage to make friends with these forms of life, and be willing to grant them a right to live in her world? Perhaps the reason they had to force their right to appear in such a terrifying way could be because she refused it to them and be­cause she was cruel to them.

The intent of all these "Why not?" questions was to let the patient see that the analyst's attitude differed from that of her mother, whose prudery and fanatical cleanliness had made her daughter's life such a misery. It was to show her that he was kindly disposed toward realms of even the lowliest of life's creatures, that one could really be open, unafraid, and accepting of these realms of beings. Actually, the patient had already sensed this prior to the questions, within the first few minutes of her meeting him. Otherwise it would certainly no more have "occurred" to her to mention the snake symptom to him than to any of the previous doctors, whose concern with the patient had remained confined to an objective assessment of her bodily functions. Much more crucial than anything the analyst says is his actual human openness to every realm of life belonging to the patient's existence. On the other hand, the analyst was extremely careful to avoid offering any sort of "deeper" symbolic interpretation of the snake pictures, by calling them phallic symbols, for instance. As it emerged much later, the patient herself had read such interpretations in psychoanalytic books years before. Needless to say, they had been devoid of any meaning for her, and had had not the faintest effect upon her, try as she had to believe them. The analyst did not avoid the penis interpretation of the snakes and worms merely because this would have been premature. For him it would have been quite the opposite of a "deep" interpretation, a too superficial one, because it hedged the essential meaning-content of the phenomenon with restrictions, and fell short of grasping its basic significance. Therefore he let the snakes and worms remain the patient's snakes and worms; he listened attentively, however, to hear of what kind of a world and of what possibilities of behavior

150 Daseinsanakjtic Re-evaluation of Psychoanalytic Doctrine of Neuroses

the snakes themselves spoke to the patient. For her, the patient said, there was something about them that was sinister, something un­known, anonymous, something that shot out of the darkness of the earth unpredictably, something low, bestial, instinct-driven, loathe-some, that had not detached itself through even rudimentary legs from groveling on the earth, incapable of rising above this vile level, something too, that could attack, in the most dangerous manner, could insinuate itself into one unawares, through the tiniest scratch or opening, and poison and pollute.

The analyst pursued his encouraging questions further; why wasn't she able to see any but hateful and destructive features of her snakes and worms?

After many months of desperate resistance, the patient began to grasp the fact that she had to come to grips with these importunate creatures and to face the challenge they thrust upon her. After all, the net result of her everlastingly running away from them had been that they had attached themselves all the more firmly to her, dogging her very steps in the form of menacing tormentors. At long last she dared one day to make the plunge into the depths of this welter of low animals. Needless to say, she did this first by way of a dream. Her dream is presented in Figure 3.

In this nocturnal venture she flung herself courageously into the depths of the sea. There, innumerable slimy slithering tentacles of octopi and other monsters came clutching at her from all sides. What really congealed her in horror, though, was a dark and hideous form of a woman, who rose up from the ooze of the bottom of the sea and made toward her. A long red tongue flickered from the mouth of this spectral woman of the sea. This denizen of the under­world proceeded to draw the dreamer irresistibly down into the depths, sucking her into herself until she felt fused into her. That was the end of this hideous dream. From this point on, even in her waking state, the snakes and worms encroached ever closer upon her body (see Figure 4).

Finally the creatures, as "hallucinations," forced their way actually inside her body and gave her the feeling of being bursting full of snakes and worms; she puts this into form in Figure 5.

It was especially her belly that she believed to be infested and riddled with vermiform creatures. Then they began to spread to her breast, to her arms, her legs. Finally she was beset by the constant fear that the snakes and worms would at any moment wriggle out

A Patient Who Suffered Alternately from Colitis and Migraine 151

of her mouth. Then they thrust right up to her brain. It was in this phase of the analysis that she began suddenly (and for the first time in her life) to suffer from unusually severe migraine attacks. One could^searcely blame the patient that she complained bitterly over tluYinitial "success" of the analysis, and reproached the therapy for having added to her misery rather than relieving it.

However ungratifying the analytic therapy might, for the present, appear to the patient, it had already yielded the analyst invaluable insights into the core of her being. Indeed the dreams, delusions, and hallucinations of this colitis patient had indicated to him that the earthy, creature-like "animal" and instinct-driven phenomena of his patient's existence had already, to an extent, forced access to her awareness. Yet she was wholly taken up in fighting off acceptance of them, so completely and utterly, in fact, that she was left entirely bereft of any base or footing of her own and had—by defending herself so desperately against accepting them—delivered herself over body and soul to precisely that which she so ruthlessly resisted. This is why in the first of her pictures (Figure 1) the snakes and worms (suspended in space and devoid of any base) have ap­propriated all the available space, encroaching into every nook and cranny. What she rejected assumed for her reptilian "cold-blooded" form—snakes and worms, rather than, for instance, a dog—which indicated further how remote was her withdrawal from every inti­mation of such possibilities in life. For, obviously the relation be­tween a human being and a "warm-blooded" dog is much closer than that between a human being and reptiles.

With her first decision, on her own, to give up the tactics of sheer flight and to face the onslaught of the animals, the patient became accessible to the awareness that the reptilean way of living could also have a place in human existence. Hence, at this juncture, the emergence of the mermaid with the snake-like tongue. In this apparition, though, the "animalish, instinct-driven" still appeared to her as ominous, vile, and slimy, and as something which must be resisted at all costs. It was not yet possible for her to take the "animalish, instinct-driven" possibilities of world-relationships to her­self and acknowledge them positively as belonging to her own existence. As yet, she could endure to look at them only from the outside, could perceive them only through another woman. But the slithery mermaid overwhelmed her, swallowed up the innocent, guileless juvenility of the patient, which thus far had prescribed

152 Daseinsanalytic Re-evaluation of Psychoanalytic Doctrine of Neuroses

the limits within which she had dared to live. Based as it was in this perilous attitude of defense against an overwhelming some­thing, her life during the day was similarly rooted in a sustained and, as she^put it, "stupid, senseless fear." This the patient was reluctant to allow. But the more she objected to bringing into the sphere of overt awareness and voluntary decision this abhorrence of any concourse with what allegedly was lowly, animal and earthy, the more this all-determining exclusively defensive attitude of her life could occur only within the visceral and excremental realm of her existence, lodged, unrecognized, in her very entrails. Accord­ingly, her intestine functioned, in relation to her own stool, as though she received a daily portion of the most revolting poison, which it was imperative to expel with the utmost vehemence and dispatch.

This so-called organ-neurotic symptom showed us, no less than her later hysterical gestures, how true it is to speak of the bodily realm of man as of a partial sphere of our human existence, which, as we have seen, consists of nothing but our possibilities of relating to what we encounter. How else could the intestines of our patient have been so completely in accord with her attitude or her world-relationship of a warding-off of everything earthy? Better still, how else could this specific kind of relationship to a certain realm of her world have occurred as and in the form of these bodily phe­nomena only?

Only in the subsequent course of the analysis did the patient become aware that she was warding off something explicitly, and of what was involved in this resistance, namely her abdication to the creature-like realms of the human world. For some time already, she had been unable to detach these animal phenomena completely from herself and to invest them somewhere externally, in worms and snakes suspended in a vacuum. But the idea that her resistance amounted to a disavowal of anything having to do with the potential existence of a whole realm of life, that it was, in fact, tantamount to her disowning something pledged to her and intrinsically her own— this thought remained, for the present, revolting to her. But the more this knowledge began to ascend toward her head, in spite of all efforts to the contrary, the more the awareness of worm-like possibilities in life actually clamored on her brain (to use the language of her pictures), the more her head itself became involved, participated quite literally. As might be expected, this participation

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A Patient Who Suffered Alternately from Colitis and Migraine 153

of her head also came to pass, at first, as a spastic rejection as formerly had been the case with her intestines. This was the stage at which the severe migraine first occurred. In the months that followed, it was possible to detect a constantly alternating occur­rence. The more she could admit an overt, reflecting awareness of ЬегЧгие attitude, the more prominent became the new symptom of migraine. Conversely, the more she defended herself against this knowledge and tried to hide it, the more she relapsed into the old colitis symptomatology. More than two years elapsed, years fraught with crisis and laden with difficulties for both analyst and patient, before the patient was able to achieve an open and free relationship to the animal phenomena in her world. With her growing open ac­ceptance of these potentialities in life, came a real danger that on the plane of direct, volitional interpersonal relationships she herself would completely capitulate to this "animal" relatedness to the world, and would, in short, become a whore. In that event, one would have achieved no more, with analysis, than that against which Freud warned. One should not, he wrote, accept for analysis patients in whom the optimal achievement to be striven for is the conversion of neurotic suffering into ordinary suffering. This would have been the case if one had been content to let things rest with the restitu­tion of her productive ability and an unimpaired capacity for sexual enjoyment—with the achievement, in other words, of "genital primacy" and complete orgastic potency.

After a few more months of analysis, however, the patient, trans­formed meanwhile into a highly sensuous, impulsive being, produced a drawing which reveals a completely new aspect (Figure 6).

At first glance nothing has altered. The worms and snakes and similar creatures remain as before. But on closer inspection, one sees a sort of sun in the middle, the first flicker of a spiritual light. And without the analyst's mentioning a word about religion to this erst­while completely atheistic patient, this sun opened out sponta­neously in succeeding drawings. In its center the figure of Christ appears, brooding over the germ of a human life, clasped in his arms, with all its earthen colors and its fleshliness (Figure 7). A little later this embryo becomes a girl, who surmounts the instinct welter of animalness and raises herself to the cross (Figure 8). A few days later, a church bell has taken the place of the snakes. (Figure 9). And by the end of the therapy, the patient experiences

154 Daseinsanalytic Re-evaluation of Psychoanalytic Doctrine of Neuroses

a radiant light within her, which she reproduces as shown in Figure 10.

This light is powerful enough to wrest from the surrounding darkness a large sphere of human existence which is secure. Once ^-traving found himself, with all his potentialities of relating that which he encounters within the fearless freedom of such a light— and so long as he is able to remain within it—no person need suffer any longer from colitis or migraine. Without the subject having been touched upon in the analysis, the patient no longer needed to fear the erstwhile "allergens" as something hostile and malign, nor react against them with an idiosyncrasy. She could eat several chive sandwiches and an entire bar of chocolate now without suffering the slightest discomfort. Previously, when her whole being was still nothing but craven fear and frenzied defense against everything earthy, excremental, low, and of the creature world, a comparable quantity of "antibodies" would, most surely, have brought her close to death. Nor was the patient any longer in danger of losing herself as a whore. With the restitution of her physical health, she had become capable of a much more mature human love. It is now sixteen years since she married, and in this time she has been a good mother to three children.

A^Patient with Functional and Structural "Psychosomatic" Disturbances

Life History and History of the Illness

The next case, that of a woman whom we will call Maria, is particularly well suited to illustrate the Daseinsanalytic approach, because the patient was ill and under medical supervision over a period of twelve years and because, during this time, her symptoms changed constantly.

Maria's home was a small village in Switzerland, a community where everybody knew everybody else intimately. Her family were regarded as industrious, run-of-the-mill people. One uncle on the mother's side is said to have committed suicide after he put up bail for someone and was left "holding the bag," losing half of his fortune. The patient's father, as the therapist got to know him, was tall, lean, quiet, and distant. He seemed completely absorbed in his occupations as teacher and village clerk and apparently had never found time to pay serious attention to his only child. He was therefore unable to tell much about the patient's development, nor could he describe her characteristics. The mother, on the other hand, had remembered in detail all the events of her daughter's life history, back to and including her birth.¹ In contrast to the father, the mother had been fairly obese. She had overflowed, not only physically but figuratively, in her motherly concern for her child. Every time she had told of a new phase of suffering that her daugh­ter had gone through, her tears had flowed amply.

If one reduces the mother's report, plus information from five

¹ The patient's mother died before the onset of her daughter's psychoanalysis; all statements attributed to her are either taken from reports of physicans who had treated the patient prior to analysis, or are based on what the patient reported about her.

f 156 Daseinsanalytic Re-evaluation of Psychoanalytic Doctrine of Neuroses

j other relatives, to the questions which interest us most, one notices an impressive bifurcation of Maria's life history. She was breast-fed for eight months without showing any signs of illness. She was healthy all through infancy and childhood. In fact, up to the time when she began to menstruate (at age twelve) a healthier, happier, and more amiable child could not be imagined. In school she was always one of the best students, and her sunny disposition made her very popular with the other girls. There seems to have been just one period in the patient's life before puberty when she was notice­ably unusual. From the age of three years until she was about five, she had been a problem eater. She had strictly refused to eat tomatoes and had resisted, as best she could, eating meat. During the same period she suffered from nightmares for a few months, dreaming of witches, robbers, and fire. All these difficulties disap­peared on their own and had been all but forgotten by the patient as well as by those around her. Only insistent and pointed questions were able to bring them back to her mind.

A year and a half after the beginning of menstruation—shortly after the patient's fourteenth birthday—her behavior underwent an incomprehensible change. Looking back, she recognized that this time constituted a decisive turn in her life and marked the begin­ning of almost ceaseless suffering. Up to that time she had been exuberantly affectionate with her mother—had clung to her skirts and could never caress and kiss her enough. Now she began to withdraw from her and to criticize her in various ways. Above all she resented her mother's obesity. At times this would lead to temper tantrums during which she would call her mother a dis­gusting sow. During this same period the patient discovered tend­encies toward obesity in herself. She began to tie up her developing breasts, and she put herself on a starvation diet. Food as such became repugnant. The mere smell of meat and fat, above all, caused the patient to become nauseated. Vegetables and fruit juices, on the other hand, she tolerated. The most conspicuous result of her dietary regimen was a loss of weight to the point of emaciation. She now weighed only sixty-two pounds, although she had grown to five feet. Her menstrual periods stopped. She was given ovarian hormones, which alleviated—comparatively easily— her amenorrhea but also produced emotional tensions and irritability of such severity that medication had to be discontinued. Menstrua­tion ceased again. Treatments with insulin and adrenal cortical

A Patient with Functional and Structural "Psychosomatic" Disturbances 157

hormones produced similar, merely temporary, results. Eventually all medical treatment was stopped and replaced by exhortations to have patience. It was all right if her weight did not fall below sixty-five pounds; no one expected it to keep pace with her con­tinued growth. Of those concerned, the patient least of all objected to her subnormal weight. In spite of her alarming thinness she retained her energies and purposefully pursued teacher training.

At seventeen she experienced, for the first time in her life, a certain liking for a man. He was a fellow student in teacher train­ing school, die only one who was almost as thin as she was. What she liked about him most was that he was so very different from all the others, and not just physically. He was a very sensitive fellow who disliked noisy activities and lived only for the most exquisite poetry. A purely ethereal friendship developed between them, hardly ever expressed except by mutual recitations of poems. The patient kept this friendship secret from both parents and physi­cians. They were thus surprised to notice that she began to bloom suddenly, regained her normal weight within a few weeks without any kind of treatment, and even began to menstruate again. This phase lasted for more than a year, until her nineteenth birthday. It was to be the last happy and healthy phase for a long time.

To celebrate her nineteenth birthday, Maria had asked for and received permission to go to a dance by herself for the first time. The occasion, the twenty-fifth anniversary of the music society of her native village, was to be celebrated with considerable display. The two secret lovers planned to meet at this dance as if by ac­cident. When the long-expected night arrived, however, Maria's friend became ill after the first dance, began to throw up, and ran home. Before he left he asked Maria to wait for him. He would probably feel better soon and would then return. When it was almost midnight and her friend had still not returned, she accepted another fellow's invitation to dance. She even accepted his in­vitation to go for a walk after the dance because she could no longer stand the smoky air of the dance hall. No sooner had they walked the short distance to a grove of woods than her companion threw her on the ground and threw himself on top of her. Maria experienced the scene—insofar as she could comprehend it at all, being still very unenlightened as to sexual matters—as rape. What actually took place she could not clearly remember, except that she had been almost out of her mind with fear. In spite of her

158 Daseinsanalytic Re-evaluation of Psychoanalytic Doctrine of Neuroaa

panic, however, she had enough strength left to tear herself loose and run home. She ran into her parent's bedroom, threw herself on the floor in front of her mother's bed, flailed her arms, cried, yelled, and tore her hair. A physician was called who gave her an injection which quieted her down. The next day he talked to her and his friendly and reasonable manner seemed to be effective; she regained her customary good humor within a few days. At odd moments, however, tears would come to her eyes—but she did not know why.

It seemed that the only one who really suffered permanently from the experience was her former boy friend. From the night of the attack, Maria had an unsurmountable aversion against him and would not let him come near her. Neither her appetite nor her sleep were affected by the incident, however. All the greater the surprise when suddenly, six weeks later, the following incident occurred at lunch. First she let herself slip to the floor, where she lay un­conscious for several minutes. Then, "as if some vile magic had her in its grip," she bent back until her whole body was in a "back-bend," as dancers call it. Her mother had added blushingly that, while in this position, her daughter had made strange rhythmic movements with her pelvis. The physician arrived just in time to witness the last moments of a classic arc-de-cercle. Soon the patient got up, as if out of a deep sleep. She recognized and greeted the doctor with an expression on her face which he had never seen on her before. He described it as an unnatural, sweetish smile, char­acterized by abnormally bright eyes full of erotic desire. He stated that although he was only a general practitioner he had had no doubt that this was a typical fades hysterica.

After that these attacks recurred regularly every second or third day, until the physician was able to convince the frightened parents that their daughter's condition was not dangerous but imaginary and due to "nerves." The parents, unusually understanding, fol­lowed the doctors' advice not to pay any more attention to the attacks, to leave the girl more to herself, and to treat her more coolly. To the girl the physician hinted carefully that her attacks might have something to do with the shock of the rape scene which she had not quite overcome. These measures were sufficient to make the loud hysterical symptoms disappear within ten weeks. Everybody was thankful that Maria had again recovered. Soon,

A Patient with Functional and Structural "Psychosomatic" Disturbances 159

however, she developed another ailment. After nine months she had to consult a gynecologist because she was suffering from fluor albus of such intensity that her regular physician had been unable to cure it. The specialist tried everything in his power, but for a year and a half all his attempts remained unsuccessful. Eventually he asked for and received permission from Maria's parents to refer her to a psychotherapist.

The patient's first psychotherapy consisted in weekly hypnotic sessions during which the therapist gave the post-hypnotic sug­gestion that her gynecological symptoms would improve from day to day. This simple treatment showed surprisingly fast results. After four weeks the discharge had stopped completely and the psychi­atric treatments were terminated. Maria remained in a strangely depressive mood, however; she could not understand why she did not enjoy the cessation of her symptoms more than she did. Soon her emotional burden expressed itself somatically as pressure in her chest and heart. It became increasingly difficult for her to breathe and occasionally she experienced a rapid increase of the heart rate. Her heart would stop beating for a second or two and then continue at an accelerated rate, throwing her into great anxiety. She felt as if her chest had become too small, as if her heart would burst. Six months after the termination of the hypnotic treatment she was forced to consult a cardiologist, who soon diagnosed a severe cardiac neurosis. He prescribed sedatives, which were only temporarily effective. Disappointed, Maria consulted another internist. During the following five years she went from one physician to another to seek relief. The eighth cardiologist whom she consulted (during the fourth year after 'the onset of cardiac symptoms) detected for the first time "objective" symptoms of cardiac failure: her shortness of breath increased noticeably during physical labor, and in the evenings her feet and calves were often edematous. The specialist suspected at first that the insufficiency was due at least partly to the strange weight increase which had occurred during the preceding year. But to his surprise the heart symptoms disappeared of themselves when the patient gained even more weight. At the age of twenty-six, she reached her greatest weight, but was no longer aware of her heart at all. She weighed one hundred ninety-three pounds and was five feet five inches tall.

When Maria began to become obese, her interpersonal relation-

160 Daseinsanalytic Re-evaluation of Psychoanalytic Doctrine of Neuroses

ships also changed. Until this time she had fulfilled her various teaching duties energetically and enterprisingly in spite of her many ailments. She had permitted her professional duties to take up most of her time, so that little remained for friendly relations with colleagues. Now her vitality gradually lessened. She no longer had any good ideas for teaching, and her interest in her occupation grew weaker. Whereas she had before been extremely sensitive as far as her teaching was concerned she now did not care at all when she was reprimanded by the school board for indifference and lack of initiative. Eating had become her prime interest in life.

From time to time she tried to bridle her voraciousness and to follow the diet her physician had prescribed. Such attempts never lasted long, because no sooner did she start fasting than she began to feel unbearably uncomfortable, a feeling which soon grew to unexplainable panic. For the same reason she absolutely refused to enter a hospital for purposes of reducing, as her physician sug­gested. As long as she did not follow his advice and filled herself with sweets, she regained her composure and felt that she had no problems. The result was that she spent a fifth of her monthly salary on food.

By this time the patient's physical and mental state was ob­viously abnormal. An endocrinologist was consulted. He noticed signs suggesting Cushing's syndrome—namely, the characteristic fat distribution, the personality changes associated with endocrine disturbances—such as apathy, phases of depression, and decreased sexual desire—and a significantly elevated BMR. Surgery was con­sidered, to extirpate the greater part of the hypertrophied adrenal cortex. Before the final decision was mude a second psychotherapist was asked for his opinion. He suggested psychoanalysis and the patient decided to follow his advice.

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