From the Division of Psychiatry, University of California Medical School, and the Langley Porter Clinic, San Francisco, California.
This is the third paper in a series entitled: Experiments in Psychotherapy.
IN A STUDY of the personality of patients suffering from post-traumatic syndromes (30, 31, 32), chronic disease in general (33), duo-denal ulcer (35), and thyroid conditions (34) it became more and more apparent that a common denominator existed in the majority of these psy-chosomatic conditions. Symptomatology (33), per-sonality structure (40), as well as social techniques (37) of these patients pointed to a rather primitive level of psychologic organization. Further evidence for immaturity was found in the need for modifica-tion of psychotherapeutic procedures commonly employed in the treatment of psychoneuroses for use in the rehabilitation of these patients (33). The common denominator then was identified as re-lated to faulty or arrested maturation, and somatic manifestations were recognized as constituting means of infantile self-expression. In the present paper an attempt is^made to discuss the immature personality as related to psychosomatic conditions, thus providing a better understanding of the psy-chotherapeutic needs of these patients.
Theoretical Considerations
When an individual goes through the various phases of psycho-physical development and then breaks down, terms such as fixation and regression have been introduced to denote that the individual returned to previous levels of adjustment and gratification (18, 20), and if an individual ex-presses certain repressed conflicts by means of symbolic physical symptoms, this process is called conversion (19). Most of these concepts have been derived from the study of highly organized and complex types of psychoneuroses (15). Then, some years ago, the attention of the psychiatrist shifted to the psychosomatic conditions. Though the con-cept of conversion was separated from the concept of vegetative neuroses (4), the attempts at corre-lating specific conflict situations with specific syn-dromes implied the use of the concepts of conver-sion and regression (2). At closer examination of these reports (12), however, one is struck by the importance which various authors (7, ri, 22, 27, 42, 44) attribute to features such as dependence, low frustration tolerance, vegetative or autonomic manifestations, specific and stereotype somatic re-actions to various types of frustration, and poor or one-sided manipulative ability of these patients. All features mentioned are characteristic of immature personalities and tend to corroborate the author's own conclusions (38, 40). Therefore, it seems justifiable to state how some of the theoretical concepts and therapeutic methods used in the treat-ment of complex and organized psychoneuroses have to be modified when applied to psychosomatic conditions. In the psychoneuroses we deal with a pathologic development, while in psychosomatic conditions one meets primarily arrested develop-ment. Some of these infantile patients, for example, have persisted since childhood in expressing them-selves in somatic terms, though visible pathology developed only after certain habits persisted for a number of years. In these cases it would be erron-eous to apply terms such as regression and conver-sion, when in reality a lack of progression has existed, to which attention is called when physical pathology is discovered. Rehabilitation in such cases is frequently a modified form of child psycho-therapy with chronologically adult patients.
Thus the most relevant clinical problem in psy-chosomatic conditions seems to center around the level of organization at which patients habitually operate. Since maturation is understood best in terms of social learning, reference will be made to the concepts of drive, cue, response, and reward (26). A drive impels a person to respond; a re-sponse as such is action, at first nonsystematized and later learned and organized. Cues determine when and where an individual will respond and which responses he will make. Whether a given response or action will be repeated depends on whether or not it is going to be rewarded. The process of emotional and intellectual maturation, then, consists of correct generalization of responses from the physical to the social sphere, acquisition of cues, discrimination, symbolic self-expression, de-velopment of social techniques and, finally, in-tegration. The state of maturity (6, 43, 45) as op-posed to the state of immaturity (21, 24, 25) is characterized by essentially three features: a) suc-cessful functioning as an independent unit with gratification of wishes in terms of the culture in which the individual lives (36); b) successful bio-logic and social interaction with other people (37); c) self-expression, self-extension, self-objectivation (6, 36). As space precludes further elaboration of the concepts set forth, the reader is referred to the original publications (36, 37). In applying the theory outlined, one arrives at the following illus-tration of the immature personality.
Arrested or Faulty Social Learning