A Psychodynamic Study of the Recovery of Two Schizophrenic Cases

French, T.M. and Kasanin, J (1941). Psychoanalytic Quarterly, 10:1-22.

Every psychiatrist has had cases that seemed to be hopelessly involved in schizophrenic psychotic processes but which nevertheless, after some months or years, have set all his gloomy prognostications at naught, some even achieving on recovery a better social adjustment than had been possible before the illness. Sometimes these cases are dismissed as merely further evidence of the uncertainty of psychiatric diagnosis. Such cases, however, should challenge us to try to understand psychodynamically just what the process was by which the unexpected recovery took place or to answer if possible the paradoxical question of why it was necessary for these patients to develop a psychosis as a step in the process of achieving a better adaptation to life.

In this paper we wish to present two such cases who underwent no treatment other than the good physical care and sympathetic interest in the patient's communications which is offered in every good psychiatric hospital, but who nevertheless achieved unexpected recovery.

The points that we wish to illustrate are two: (1) that an acute psychosis may be a transitional episode in the process of emancipation from an old method of adjustment and 'learning' a new one, and (2) that during the acute psychosis the mechanism of recovery may be indicated in advance by the content of some of the delusions.

Our first patient is a young woman of twenty-four, a nurse, the youngest of eight children. The parents were Italians, originally Catholics who had been converted to the Protestant faith. The patient's father was somewhat of a rebel and left home early in life; he also left his church and became a converted Protestant. He graduated from a liberal university and after coming to America he became a successful publisher. The patient's mother was an able, intelligent, intuitive person. Four years previously she had had a depression which lasted about a month. The brothers and sisters had achieved success in business and professional careers, although several of them were somewhat neurotic.

The parents were in their fifties when the patient was born. A delicate child, she was considered pretuberculous when at the ages of one and three she had swollen glands of the neck which suppurated and drained for several weeks; but with proper hygiene she developed into a healthy child.

She was occasionally bothered with night terrors and sometimes talked in her sleep, but seemed otherwise quite normal. She was a very pretty child, enjoyed being dressed up, was fussy about her clothes, and was quite spoiled and pampered by her family. As a little girl she was very fond of dolls and loved to dress them.

She had a great admiration for her brother Joe, four years older, who was always interested in what she did, although he sometimes resented her wishing to play boys' games lest she become a tomboy.

She was well adjusted in school, was quite a leader and loved to play and take care of little children. She was a hard worker, had an excellent scholastic record and graduated from high school at eighteen. After this she went into training as a nurse and subsequently specialized in public health. In 1928 she had charge of a hygiene department in a large settlement house.

The patient was brought up in a very rigid family discipline. Some of her siblings left home because their lives were minutely regulated by the parents. The patient was never allowed to go out with boys until she was twenty-two. Even then she had to be in by ten o'clock, and the mother interviewed every man she met. The patient was given a choice of a career or marriage. In as much as she was interested in a career, the parents insisted that she have nothing to do with men.

The patient was described as a charming, sweet girl, sociable, attractive, quite aggressive and somewhat snobbish. She chose her friends very carefully. She was always extremely jealous of her brothers and sisters.

After a minor operation in 1922, there was a period in which the patient became more serious, less cheerful, and quite irritable. She began to demand a great deal of her family, was critical and scolded her mother for no special reason. In the winter of 1926 there was again a short period when the patient was extremely cross with her family, especially with her brother, Joe, of whom she was very fond. She seemed to be unhappy at home and extremely absent-minded, but gradually she seemed to pull out of it. A recurrence took place in the fall of 1927–1928.

In 1929 the patient felt so restricted at home that she decided to find a job in another city. She took charge of health work in a settlement house maintained by a sectarian organization. She found the people in the settlement house rigid, narrow and meddlesome. The patient's letters home showed that she was dissatisfied and unhappy. When she visited her sister in November 1929, the latter noticed that she was very quiet and unhappy.

In a later autobiographical account, however, the patient revealed that her unhappiness had a deeper cause. The difficulty had begun with an intimacy with her brother's friend, Tracy, who made urgent sexual advances to her. As she later confessed, she had refused intercourse with him only because she was menstruating, but had yielded to tongue kissing and probably to fellatio which was very disgusting to her. Then she developed cankers in her mouth, became disgusted by everything she ate, and was sure she had syphilis.

The patient went home for Christmas. She looked for a long time at her mother who met her at the station, as if she did not recognize her. She was confused, perplexed and could not make any decisions. She brought some ties for her brothers but could not decide whether they were good enough for the boys or not. She complained of fatigue, was depressed and spoke about being a failure. In spite of her family's objections the patient went back to work. However, she feltherself to be a total failure and 'could not go back and teach those dear children again'. Her letters to her family were brief and difficult to follow.

On January 12, 1930, the patient telephoned to her sister and asked that someone come to see her. When her brother visited her, she complained that everybody was talking about her and making sarcastic remarks. She thought of committing suicide by jumping out of the window, finally going so far as to climb onto the window sill with this thought. Earlier in the evening she had taken a dose of milk of magnesia and a sedative which had been given her, but a funny taste remained in her mouth and she was sure that her associates had attempted to poison her.

On January 16, 1930, the family received a wire from the superintendent of the settlement house, stating that the patient had become unmanageable and had tried to jump out of a window. The family came to take her home and on the way home the patient made several attempts to kill herself. She said that the police had tried to flirt with her and that she had been shut in a room with a policeman so that she would be compromised. When they tried to give her a sedative she said they were giving her poison. She had a small sore on her mouth which she asserted was syphilitic. She called on God and announced that she was a sinner. She also mentioned the name of her brother's friend and said she had been intimate with him.

On January 17 she was brought to a hospital for observation. On admission the patient was quiet but uncooperative. Within a few hours she became very restless, walked a good deal, hammered at the door, cried for help and said that very strange things were happening. At times she was agitated and depressed. She called the physician again and again and said that she would be saved through Christ. For the first two days she refused all food. On the fourth day she became very quiet and underactive. She suspected that the food was poisoned and refused to drink water from the fountain. She said that strange, mysterious things had happened to her. She said that before she came to the hospital people bothered her and were against her. At the same time she was evasive and would not give any specific illustrations. She was hostile, she criticized the food and the hospital. She then lapsed into a stupor but any attempt to examine her physically elicited a violent response. Since the prognosis for quick recovery was thought to be poor, the patient was transferred to a State Hospital with the diagnosis, catatonic dementia præcox, stuporous state.

On admission to the State Hospital the patient was mute and untidy. She grimaced, gesticulated, and mumbled to herself unintelligibly. At times she was over-talkative. For a long time she wandered about the ward dirty, unresponsive, with a vacant, dull expression.

The following are excerpts from a later retrospective account of her illness:

I went through what I thought was positive hell. I believed myself to have been dead many years. I thought I had been so wicked on earth that I was not allowed to live on it any more and that only the good people were allowed to enjoy its luxuries. It seemed like years and years instead of days and days. To be really dead was my only craving for I had no hope of ever enjoying the luxuries, if one might call them such, of my home again. If only I could have ended everything for myself…

One of the patients reminded me so of Tracy's mother that I felt it was she. I thought she was there to attend the trial. She would look in my room all the time and hated the sight of me with a profound hatred, while in reality she was quite fond of me. His father, who I imagined Dr. P. to be, hated me likewise and was so severe—so different from what he really was. One of the student doctors was Tracy. Tracy had a lot of sympathy for me now but no love. He was chagrined and would not recognize me in this condition. I was a horrible girl and he a successful surgeon…

Soon after, perhaps a week (it seemed years) of agony I found myself on a boat bound for Italy. I had been kidnapped and what not. I was relieved of my suffering to a very small degree by being taken into another world. I must now suffer for my sinful life upon earth. Consequently I was being transformed into a snake. Hence the food, cornmeal mush with molasses (Indian pudding) and plenty of milk, for snakes thrive on milk. The very hairs of my head were each one changing separately into a snake. I myself was going to be a huge one. These thoughts sent shivers through me. It was horror again. No one can believe, no one can understand—for it was so real to me, so true to life. Anyone who looked at me long enough would take on a peculiar facial expression which I thought lasted; that was why people looked in and walked away and could not bear to see me. Why did I always hide? For fear someone who had known me would see me in this condition. I heard my friends' and relatives' voices. They all wanted me to return home. I could hear them pleading with me…

I was so dissatisfied with the life that I had led and the small amount of religion which I had possessed that I determined to become a Catholic. The Catholic religion seemed to me to have more back of it (really I did not know a great deal about it). They had to confess their sins to the priest while we kept everything hidden within ourselves and lived our lives as we chose. Attending church was optional. What sort of religion was this, the Congregational faith? Merely effective, nothing more. Consequently I became (I sincerely believed) a Catholic. I spoke to the attendants about it and they were unusually sympathetic. I waited for a priest to come but apparently I was in no condition to be seen. So they put me in packs and I returned to hell once more where I remained for how long I do not remember…

The next thing I remember was being tube fed. I looked up into the doctor's face and she reminded me so much of a dear friend of mine that I felt she was there to help me. I wanted to talk to her but as I believed myself to have been dead I couldn't bring myself to do so. I wanted her back more than anything else…

Finally I felt that I had just awakened to the fact that I had been missing from my family for some months and that they were looking everywhere for me. A war had taken place on account of me, everything was wrong everywhere. My family must never find me. So I kept hiding. Consequently when my father came I did not want him near me. First because I had been dead. I was now Catholic and then too they were apt to look him up and molest him. I alone knew the extent of his goodness upon earth. He brought me ice cream. How absurd this seemed to me. To please him, however, I often ate it…

Was it possible that I was really L.A.B. at one time? How was I to know? There was no mirror around. I found scars on my legs which were there before and my hair seemed to be the same. The fact too that one or two people called me Lucia. These things alone seemed to prove my identity…

The hydro is like a morgue to me. I felt they were reviving people who were dead… ["hydro" refers to hydrotherapy, explained here.]

On my return from the hydro one particular day I was sitting in the sun parlor. The doctor that tube-fed me went by. When I smiled at her she responded by coming to talk to me. Because she said she would talk to me only if I wanted her to, I was willing to try. She asked me what I wanted most. I said "a chance to live again". When she said that I would have this opportunity, it seemed just the most remarkable thing imaginable…

In the spring of 1930 the patient showed more interest in her environment and began to be more communicative. 'When I first discovered that there were one or two people ready to be my friends, I immediately started to improve, but not until then.'

During this period she was continually working over the problem of her relations with Tracy, at times realistically.

Another thing: Tracy always got awfully excited when he loved me… He was one year younger than I was but he was old for his age. But I think he was in love with me. I think he likes me a lot but he has other girls. He never talked seriously of marriage. He told me I was the woman but I don't think he meant it. He did not know his own mind. He did many other things which were repulsive to me. I knew other girls did it. I don't like to think that he has done to other girls what he did to me…

I always loved my brother, Joe, even if I got awfully mad at him sometimes. He didn't want me to do things with boys that he did with girls. He said a fellow can get away with it. A man doesn't want a girl that everyone had. The fact that I would do anything more than hold hands with a fellow was repulsive to Joe. I always knew that Joe and my family thought so highly of me that they could not think I went as far as I did…

The day you tube-fed me I would have been dead if you had not spoken to me. The others didn't. I knew I nearly died and I tried very hard to die. I think the idea of my favorite brother, Joe, kept me more alive than anything else, even more than my father and mother…

I thought when my case was read that I was at a trial. I thought the superintendent of the hospital was a judge and that the people could not get out of the hospital. They were being suffocated. The world had stopped. The minute any foreigner came around I thought I was in Italy. I thought I was in Italy when Francesca started raving at me in Italian.

In the spring of 1930 the patient went home for a trial visit but she had to return to the hospital because she was very unstable, had severe temper tantrums and scolded her family. In the hospital the patient was extremely impulsive and several times attacked nurses and threw things at them. She continued to improve, however, and in the summer of 1930 she was discharged on parole. She was seen by the psychiatrist once or twice a week through the summer, fall and winter of 1930–1931. Throughout this period the patient was very anxious to come, never missed an appointment, was eager to talk about herself and constantly sought direction and guidance. She was like a small child who begged to be led.

During this period she met a young man who was her favorite brother's best friend. Gradually the two fell in love with each other. She would ask for detailed instructions to govern her conduct with this young man and when she was told she might conduct herself in any way she thought best, she would inform us immediately that that was exactly what she had been doing. When she asked, for example, if it were advisible for her to have relations with the man to whom she was engaged, as both felt very passionate, she was told that since they felt that way and since she was sure to marry the man, there were no real objections. Then the patient stated that she had already done it. It seemed as if she wanted her behavior condoned rather than permitted.

The young man whom she subsequently married was an unstable, somewhat immature person who had been married previously to an inferior person who left him with a feeble-minded child. His family was also very erratic, although wealthy and prominent socially. The patient thus had to contend with a very difficult situation which she handled with unusual intelligence and skill. She gradually won over to her side the members of her husband's family, gave extraordinarily good care to the feeble-minded child, and for several years took care of it until the husband of his own accord suggested that the child be placed in an institution. Then the patient became pregnant and had a normal pregnancy and delivery. She and her husband had to weather many economic difficulties as the latter had a difficult time during the depression before he obtained a satisfactory position as an engineer. The patient, with whom we have kept in rather close touch, impresses one at present as a stable, mature, intelligent woman with a good deal of social poise, tact and judgment.

It will be noted that her psychosis followed the patient's first attempt at supporting herself away from home and was a reaction to a sexual experience which was at great variance with the moral traditions of the family. Significant also is the fact that even prior to the psychosis the patient was at least consciously and intellectually beginning to free herself from the overstrict standards of the mother. This is indicated by her insistence that she loved the man in spite of her disgust on account of the character of their sexual intimacies and also by her frank admission that a normal sexual relationship would have occurred had she not been menstruating at the time.

Her psychotic reaction makes it plain, however, that emotionally she was not so fully emancipated as her conscious attitudes would suggest. The central motive of her psychosis is punishment and at the height of her psychosis she experiences an acute estrangement from this newer self that had attempted to act in disregard of the puritanical attitudes of the parental home. She is dead, she is not herself. She is being transformed into a snake, a symbol of the sexuality which her conscience so loathes. People walk away and cannot bear to see her. She must hide from her family.

But then, under cover of these delusions of punishment and loathing, comes a first hint of a new trend. She is being kidnapped and carried back to the Catholic country from which her parents had come. The significance of this is not immediately plain until she tells us soon afterward that she has become a Catholic and extols the confession as a better means of dealing with guilt than trying 'to keep everything hidden in ourselves and living our lives as we choose'.

In the light of the specific facts of the patient's family history we can now sense that this delusion of being taken back to Italy has a hitherto unexpected meaning. The parents were converted Catholics and had the puritanical zeal of converts. The patient senses this and wishes to turn away from a religion that puts such a great burden upon the conscience, back to a religion that allows confession and absolution. She wishes to return not only to the land but also to the first faith of her parents.

We may perhaps even suspect a new meaning in her delusion of being transformed into a snake. Snakes thrive on milk, she tells us. The snake is not only a symbol of her sexuality but also of her desire to be fed. We suspect that she desires not only physical but also spiritual food. She wishes for someone to teach her what to do with this problem of trying to reconcile her sexuality with the demands of conscience.

Thus in these little details of her delusions and then more plainly in her own account of her motives for wishing to become a Catholic, the patient has given us the clue to the secret of her recovery. From now on the need for someone to whom she may 'confess' her problems receives more and more overt expression and her recovery proceeds apace. During the same period a process of reality testing is setting in. She looks at the scars on her legs and wonders if she is really dead, if she may not be herself after all. After a time she brings herself to speak to her psychiatrist. She writes an account of her illness, upon which much of this history is based, and in this document is already beginning to turn over in her mind in a realistic way the problems presented by her sexual experience with Tracy. After returning home she continues to seek instruction from her psychiatrist. After a time she begins again to experiment with living according to the less rigid standards that correspond to her own intellectual convictions; but in this for a considerable period she still needs the moral support of her psychiatrist. Most significant and favorable for the stability of her recovery, however, is the fact that she seeks not so much permission in advance, as approval afterward for her steps towards emancipation.

It appears indeed that during the psychosis something happened in the patient's personality which eventuated in a healthier integration. Prior to her psychosis, under her mother's influence she had chosen a career instead of marriage. After her psychosis she married and adjusted successfully to a difficult marital situation. It looks as if her psychosis were an episode in the sexual experimentation, in this case considerably delayed, which normally occurs at puberty. After the psychosis is over she achieved a marital adjustment which would probably have been impossible before.

As one of us has pointed out in a previous paper,1 the process of 'learning' to substitute a new mode of adjustment for an older one often involves a period of frustration and despair due to the fact that one has abandoned the earlier form of
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1 French, Thomas M.: A Clinical Study of Learning in the Course of a Psychoanalytic Treatment. Psychoanalytic Quarterly, V, 1936, pp. 148–94.

gratification' and has not yet found or become secure in the new one. 'Each step in learning involves the substitution of a new for an old method of obtaining gratification. The incentive to search for a new method of gratification must be derived from insight into the fact that the old method is no longer adequate. However, the realization that an old method of gratification is unsatisfactory does not lead to the immediate acquisition of a new one. It merely initiates a period of experimentation. The first experiments are apt not to be successful; consequently, the experimentation tends to be punctuated by periods of frustration and despair, for the experimenter has now lost his old method of gratification and has as yet found no new one to take its place.'

As we have just seen, this patient's psychosis can best be understood in terms of just such a learning process. The patient was the youngest of eight children, the 'baby' of the family, much spoiled and pampered. It was not easy for her to give up this position; but the rigid puritanical standards of her family made it even more than usually difficult for her to achieve any sort of frank and sensible attitude towards her sexual impulses without sacrificing her position in the family. Nevertheless, just prior to her psychosis she made her first steps towards her emancipation. She left home and accepted willingly for the first time the sexual advances of a man. Her psychosis broke out when she first fully sensed that this sort of sexual freedom must necessarily estrange her from her family and deprive her of her position as the favorite and youngest child. In her psychosis we can distinguish two main dynamic trends in relation to this 'learning' process. The patient first experienced the acute frustration, rage and guilt which arose from the realization of complete estrangement from her family and their standards; then gradually, step by step, there emerged the urge to continue the learning process, to renew her experiment this time with the moral support of the psychiatrist, to try again to live no longer according to standards imposed by the parents, but now according to her own intellectual convictions.

In the following case the solving of a problem is the central theme of the patient's psychosis.

The patient was a nineteen year old boy, a student, the fourth of seven children. The paternal grandmother and paternal aunt were patients in mental hospital. The father was a quiet, intelligent, successful business man, the mother a very pleasant, motherly person, extremely found of the boy. The family atmosphere was reported to be unusually warm and harmonious. The patient is said to have been very happy at home. There was an ordinary amount of teasing by his older brothers. The patient's physical development had been normal except for a high degree of myopia which necessitated his wearing glasses.

He was a very serious, earnest, overconscientious youngster who was regarded as an 'odd stick' within the family and was teased in school and at home because he had no interest in games but was much more interested in his studies at school. He graduated from high school at the head of his class. He played the flute in the orchestra and was an enthusiastic collector of stamps, arrowheads and coins. He was very fond of going to the woods and identifying birds; he occasionally stuffed birds. He was an active correspondent with people in foreign lands, worked on a boy's magazine and in search of stamps carried on an extensive correspondence with people all over the world. He was a sensitive, shy boy and always felt alone in a crowd. He had few friends and did not care to mix with people. He felt that there was a good deal of stupidity around him. He was very self-conscious and worried over the fact that he might make a fool of himself. On the other hand he was very stubborn and expected everybody to accept his ideas. When his ideas were made fun of he would withdraw into himself and shut up like a clam.

The patient disliked church and organized religion, but liked to pray by himself and was very much interested in the mystical and the occult. He was disgusted with the perfunctory way in which grace was said at camp. Some time before his illness he started a very extensive correspondence with a woman in Cyprus who wrote religious letters to him.

At the age of five there had been a good deal of mutual exhibitionism with other little boys and girls. He suffered from enuresis until the age of eleven and was punished for it. When he was about thirteen he was initiated into masturbation at a summer camp and worried a good deal in the succeeding years because he could not break himself of the habit. With one boy whom he knew for several years at summer camp, he went through as many varieties of sexual relations as they could think of. Until after his recovery from the psychosis there had never been any attempts at heterosexual intercourse.

After graduating from high school at the age of eighteen the patient entered college in the fall of 1923. The year was an arduous one. He had to commute a long distance and the course was difficult. There is some indication that his worries about masturbation increased at this time, for in January he began to keep a record of it and succeeded in reducing its frequency.

Toward the end of June he was quite upset, and one night he had a crying spell in his room. He said he was feeling discouraged and tired. In July he went to summer camp, apparently was fairly contented there, but on returning home for a few days he complained of difficulty with one of the boys at camp and talked very loudly and insistently and acted queerly. On July 29, two days after his return to camp, he stayed out all night in a canoe on the lake. He had read in some magazine that glasses were useless, so he threw them in the lake. As he was very nearsighted he was then unable to find his way; he also lost a paddle and had to wait until the canoe drifted to shore. He was sent home the next day with a counsellor. In the evening he kept drawing diagrams which he said contained the geometrical proof of a new great religion. He forecasted a great change to come at 11:20 P.M., and said that God's time was coming. He read the Bible and said he heard hymns being sung. When the time came and nothing happened, he accepted the situation and went to his room. He spent a good deal of time with a piece of quartz glass in which he saw an angel and a picture of the woman to whom he was writing in Cyprus. The next morning he took this piece of quartz glass and began to gaze at it again. He saw a girl, a mountain, and a landscape. He spoke of the girl with great joy. In the afternoon he became very restless and accused his father of poisoning his food.

He was sent to a hospital for observation. He was extremely distressed at being brought to the hospital, cried, screamed, and demanded his clothes and his release. He refused to eat some of the food because he said it had been poisoned and had drugs in it. He was very excited but alert, and commented on the various objects he saw. He maintained that he saw in a piece of quartz glass various objects he had not seen for years. He frequently called out a girl's name and conducted conversations with her.

Physical examination showed considerable undernourishment. The urine showed a faint trace of albumin, a few white cells, and occasional granular casts. The white blood cell count was 25,000. There was no fever or other significant finding. Within two weeks both urine and white blood count had become normal.

For several months the patient was very overactive, excited, restless and rebellious, but perfectly willing to talk about his illness. He clung tenaciously to his thoughts, and for months called out 'Lucy', the name of the girl in Cyprus, with whom he conducted long conversations. He believed that she was in the hospital and perhaps on the same ward.

Reviewing his problems with his physician he brought up the fact that from the beginning he recognized that he was different from other boys and never felt at home in a crowd. At an early age he became interested in the Bible, its symbolism, and its conception of good and evil. This interest persisted through his college work where he became fascinated with formulæ: chemical, philosophic, religious and ethical. In the spring of 1924 he became interested in a memory system and became fired with the idea of finding a fundamental formula that would fit all spheres of life. He developed a very intricate, philosophical religious system which occupied all his attention and which was going to solve his problem of masturbation, his secret love affair, and his troubles at the camp. A few days before he came to the hospital he evolved a formula which, in his own opinion, relieved the tension in his mind, and more or less gave him the key to the universe which he was seeking. This was the idea that in the sexual union, man and woman came together and formed a perfect unity (the third element) thus reproducing the same formulation that he had found valid in all other spheres. This seemed the achievement of his goal and the solution of his problem. It is at this time that he became extremely detached from the rest of the world and began to receive telepathic communications from his sweetheart, a girl whom he had seen only once but with whom he corresponded extensively. The patient used a piece of quartz glass as a medium through which he might see explanations of things because it was the 'purest' substance known, and he felt that by the use of it he might be more able to achieve or at least glimpse perfection. It was while peering into this that he saw five pictures including an angel, the woman from Cyprus and others.

In the middle of November the patient became quieter and said that he no longer heard voices. He began to go home week-ends in December and was discharged on January 11, 1925. He reëntered college, taking up a technical course and graduated with honors. He finally obtained a position as a research worker in a large industry and became a very successful executive.

When seen in November 1931, he reported that his life had been quite uneventful since leaving the hospital. He had had several positions doing research work, his last position being very uninteresting but very secure.

With regard to his social relations, he stated that he had gradually become able to meet more people, that he had had several close friendships with girls with one of whom he had also had a sexual relationship. When last seen he was going with a girl whom he expected to marry soon.

Analyzing his illness, the patient said he could not reduce it to any one single factor. There were many things responsible for the breakdown, but at any rate it was a very valuable experience because it gave him a good insight into life. The overintellectualization of his adolescent years had been very harmful. He lived too much in thoughts, dreams and fantasy, without a real grasp or understanding of life. His recovery was largely influenced by the personal interest which his physician took in him.

With regard to the hallucinatory experiences, the patient states that they were the voices of various people, especially the girl he loved, which he heard in the noises of the street. He agreed with the psychiatrist that it was something like a tune which one hears in the noise of a moving train.

In this case we see a boy who from the beginning is impelled to concentrate the energy of his emotional conflicts in his intellectual functions. He is shy and feels alone in a crowd, does not get along well with other children but graduates from high school at the head of his class. He is worried about masturbation and tries to solve his problem alone by reading the Bible. Moreover his actual sexual attempts are of a distinctly investigatory nature. He tries many methods—a sort of research into the possibilities.

Due to the patient's extreme intellectualization of his conflict, it is difficult to get a complete picture of what is troubling him. In any case it is plain that he does not know what to do with his sexual impulses. He has been engaging in some sexual experimentation with another boy and now he is becoming increasingly worried about masturbation. Apparently his heterosexual impulses are still more disturbing to him for he chooses a girl at a distance, and in his psychosis dwells upon the purity of the medium through which he looks at her. One of the early acts of his psychosis—throwing away his glasses and losing his paddle while canoeing—seems to be a symbolic castration.

Thus it is plain that the patient wishes to get rid of his sexuality. His intellectual activity is a partly successful attempt at sublimation, a substitute for and a defense against the emergence of impure sexual impulses.

But this is not the only significance of his compulsive intellectual activity. Still more important is the attempt at intellectual mastery of his emotional conflicts. As the patient himself tells us, he is seeking for a formula to solve not only the problems of the universe but also the problem of masturbation and his secret love affair. The mechanism is one described by Anna Freud2 as characteristic of puberty—a displaced attempt to obtain intellectual mastery of one's own emotional conflicts by struggling to solve abstract philosophical problems.

In his psychosis he continues his attempts to master his emotional problems intellectually. The problem is to reconcile his sexual needs with the requirements of his conscience; but the conflict is too acute. The sexual urges are too intense to be quieted; the demands of conscience have become intensified as evidenced by his keeping a record of his masturbation and reducing its frequency. This results in that intense ambivalence towards seeing and knowing which is typical of the infantile sexual investigations. An irresistible fascination impels the child to look, but fear and horror impel him equally to turn away his eyes. Just so in our patient's psychosis, he throws away his glasses, he prefers not to see; but without eyes, he cannot find his way, his problem is insoluble. Symbolically he abandons the attempt to solve his own practical emotional problem, to 'paddle his own canoe'.

It would obviously be a mistake to conclude, however, that the urge to find a solution for his emotional problem has been quieted. On the contrary it forms the central motive power
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2 Freud, Anna: The Ego and the Mechanisms of Defense. London: The Hogarth Press, 1937.

for the patient's psychosis. The patient has indeed turned his eyes away from his own practical emotional problem, the problem of what to do with his sexual impulses; but the need to see, to solve a problem, is still intense. It has only been displaced into the realm of abstract thought. Instead of seeking a practical solution for his own emotional problem he seeks now an intellectual formula that will not only solve his problem of masturbation and his secret love affair, but will give him a key to the universe as well.

Thus in this psychosis, as in the previous one, we can see a struggle between two main dynamic trends in relation to a 'learning' process. His irritation with the boy in camp, his delusions of being poisoned, his demanding, rebellious behavior in the hospital and most significant of all, throwing away his glasses and losing the paddle of his canoe, are evidences of the acute frustration to be expected whenever an older method of gratification proves inadequate, and one which will endure until a new instinctual outlet can be found to replace it. Even more conspicuous in this case on the other hand, is the constructive impulse to solve the problem, an impulse whose significance is apt to be lost to us because it is partly displaced. The patient is trying to find in an intellectual formula a key to the problems of the universe instead of proceeding directly to the task of trying to find a way to reconcile his own conflicting impulses. Finally he does find an intellectual formula that satisfies him. The 'perfect unity' resulting from the sexual union between man and woman seems to him to be both the key to the universe and the solution for his own problem. His practical problem, however, is not yet solved and he continues restless and intellectually overactive for a period of some months.

Unfortunately we do not have the details of the process by which he returned to a more normal adjustment, but six or eight years later we learn that he has made a suitable adjustment in his work and apparently also in his sexual life. In his psychosis he had found relief in the thought that perfect unity resulting from the sexual union between man and woman was the key to the universe. It sounds as though this were a premonition of his later practical solution of his sexual problem in normal heterosexual relations.

It would seem therefore that this man's psychosis was again merely an episode in the task that confronts every boy at puberty, that of tearing himself away from the dependence of childhood and finding the solution for his sexual needs in a normal heterosexual relationship.

The point that distinguishes this patient's method of finding a solution from that of many other patients is the fact that this patient had to first solve his problem in the abstract before he was able to solve it concretely in his own case. This, however, is a mechanism for solving problems in everyday life and we as scientists should be least of all surprised by it as it is indeed the very mechanism that gives rise to science itself. It is often easier to solve a practical problem in two steps. In the first we attempt to solve our problem in general terms without too specific reference to the way in which we are practically and emotionally involved in it. It is this step that gives rise to scientific thought as well as to the less fruitful philosophical attempts to solve the problems of the universe. Once a general solution has been found, however, the next step must be to apply it concretely to the original practical problem. When a patient becomes lost, as this one did for a time, in philosophical speculations, there is of course always the danger that he will not be able to find his way back to the practical solution of his own problem. This is why we are apt to look upon excessive intellectual speculation of the sort shown by this patient as a sign of hopeless psychotic involvement. In this case, however, the patient did find his way back, and his practical solution was in fact the very one indicated by his intellectual formula.

Upon the basis of our review of these two cases, we feel justified in formulating a few conclusions which are indeed not really new, but only old insights placed in a slightly different light.

1. In attempting to estimate the probable outcome of a psychosis it is helpful to try to reconstruct the problem in adaptation which the psychosis is attempting to solve and then to estimate the possibilities for a successful solution in view of the actual life situation of the patient. Such an estimate is probably more important than the form of the psychosis as an index of prognosis.

The two patients described for example were involved in a problem of adaptation that is normal for puberty—that of tearing oneself away from the dependence of childhood and finding the solution for sexual needs in a normal heterosexual relationship. This is accomplished by a process of 'learning'.

2. In relation to this process of adaptation or learning, it is possible and helpful to distinguish between two main dynamic trends:

a. reactions to the acute frustration which results from the fact that an old method of gratification must be abandoned and that a new one has not yet been found;

b. the constructive impulse to solve the problem of reconciling conflicting needs.

3. It is easy to be too impressed with the destructive phenomena which are indeed apt to force themselves upon the attention of the psychiatrist because they are much more disturbing. In estimating these destructive tendencies it is important therefore to attempt to determine whether they represent the reaction to an acute but temporary frustration which will discharge itself, or whether they are giving rise to a vicious circle which leads to more and more frustration and thus makes recovery impossible.

4. The constructive urge to find a solution is very apt to be overlooked because it is hidden behind the more conspicuous and disturbing destructive phemomena and may indeed find its expression in symbolism which seems at first to have a highly regressive character. Our first patient's delusion of being transformed into a snake that 'thrives on milk' is an excellent example of just such a bizarre and disguised expression of what is really the patient's first constructive impulse toward recovery.

All this may be summed up in the two propositions with which we started: (1) that an acute psychosis may be a transitional episode in the process of emancipation from an old method of adjustment and 'learning' a new one, and (2) that the mechanism of recovery from such a psychosis may be indicated in advance during the acute psychosis by the content of some of the delusions.

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