The Immature Personality in Clinical Medicine
The dependent male or female patient repre-sents the personality disorder most frequently en-countered in clinical medicine. On superficial ex-amination one might think that some of these fe-male patients would fall under the classification of hysteria. However, upon closer scrutiny one finds that the infantile personality has experienced trau-matic events at an earlier age than the hysterical patient, resulting in a lack of integration of all sub-sequent events. Hence, sexuality cannot be inte-grated into genitality. In contrast, the hysterical personality has encountered its major traumatic events at the time of the oedipal situation, while true mastery prevails for previous experiences. However, both types, the infantile person and the hysterical personality, have factors in common. Exhibitionism, dramatization, diffuse eroticism, domination through suffering, and desire to con-trol, are outstanding. The areas of major gratifi-cation in the infantile personality are connected with intake functions, and manipulative ap-proaches and social techniques are designed for liv-ing in symbiosis. Hostile identification, imitation, and copying are therefore techniques of choice. The previously described external security systems are used to compensate for internal insecurity. In group situations the original family role of child or sibling is perpetuated, enabling these patients to apply techniques learned in childhood for the management of family members, thus obviating: the need for generalization and adaptation to so-cial situations prevailing in adult life.
Dependency requires control of hostility. Since infantile personalities cannot express tension ver-bally and in interpersonal relations, hostility has to be repressed, or expressed in terms of actions. In the former case tension states ensue, while in the second instance actions become destructive to self and the persons with whom the patient lives. In turn, the childhood history of such patients is characterized by a dominant mother (35) who used withdrawal of affection as a conditional means of education, concentrating upon herself the func-tions of authority, ideal model, and source of af-fection, or, by one or two punitive parents who gave affection only in conjunction with punish-ments. The common traumatic factors in these childhood constellations can be identified as con-sisting of erroneous timing and dosage of frustra-tion and rewards, inasmuch as either indulgence and over-gratification or deprivation and frustration made integration impossible.
Psychotherapy with Infantile Personalities
In applying traditional methods of adult psycho-therapy to treatment of infantile characters, one discovers that these methods are unable to promote maturation. The infantile character is chronologic-ally adult but emotionally a child who has scarcely ever experienced successful personal relations. Hence, necessary foundations for utilizing insight therapy are missing, inasmuch as experiences re-main isolated and integration does not take place. Verbal, gestural, or other symbols are not connected with affects and feelings, and consequently symbols have little merit for self-expression, although they can be manipulated in a manner similar to man-agement of gadgets or objects. Since insight therapy operates only when interpersonal relations and symbolic expression for the sake of communica-tion have been established, insight therapy with infantile characters is accepted on a nominal basis only. Words, sentences, and interpretations are memorized or forgotten, and like all other experi-ences they remain isolated and do not affect the functioning of the organism as a whole.
In experimenting with therapeutic methods to be used with infantile personalities (33, 34, 35) the criteria employed for assessment of results had to be based on evidence of maturation. If, after prolonged period of treatment, the patient started to integrate life experiences and began to function as a more independent unit, the method could be considered to have fulfilled its purpose. Psycho-therapy can be defined as a corrective experience which enables the patient to develop his growth potentialities. In applying this principle to infantile characters, the issue of psychotherapy becomes one of reeducation, in which benevolent firmness is absolutely essential. Therapy with infantile characters is not short, but long, usually requiring years. The frequency of interviews depends upon external circumstances and the needs of the individual case. Some patients, for example, at first cannot tolerate intense personal relations, while others sur-vive only if symbiosis is immediately established. If necessary, treatment can be interrupted for several months if certain experiences seem vital for growth and are conflicting with time and place of therapy. No rules as to external criteria of therapeutic management can be established, inasmuch as they usually constitute crutches helpful in alleviating the anxiety of the therapist rather than having a bearing upon the patient.
The first time the patient appears for therapy his experiences of failure, breakdown, or painful symptoms are utilized as motivation for coopera-tion. He will bring into the therapeutic situation memories and will relate experiences. These usually have the character of extensiveness rather than in-tensiveness, which means that they are rather ab-stract and characterized by an absence of appro-priate affects; after several hours of talking the energy is spent and the patient asks "What next?" It is at this moment that the therapist shifts the focus of attention.
Instead of discussing the nominal experiences of the patient at their face value, the therapist points to the manipulative and implicit content of the material. The patient is made aware that things happen between people, even if the verbal content does not betray any emotion. The methods of manipulation are pointed out, and, therefore, the material assumes a new significance. Long sessions of verbal production can be summarized in such sentences as "What do you really mean?" or "What is going on?" This procedure draws the patient away from meaningless use of words and gradually weans him from his external security system.
Externalization of feelings and emotions is a consistent feature of the infantile character, who, distrustful of whatever happens within himself, tends to objectivate these internal events by external "objective" measures. Instead of reliance upon his own judgment he inquires into what other people think, and instead of deciding on the basis of desires or interference cues (anger and anxiety) he looks to models in order to be able to follow suit in case of emergencies; instead of perceiving his own reactions he projects these feel-ings onto other people and concludes that they are either hostile or immoral or prejudiced peo-ple. The patient has to be made aware of all these external defensive security systems which serve the purpose of compensating for internal confusion. At first when attention is called to proprioceptive cues and the patient is asked to express himself he will relate his feelings as vague sensations, as foggi-ness, sometimes even as feelings of unreality. It has to be pointed out that for the patient every desire, each external interference, and all interferences on the part of conscience and ideals will give rise to certain proprioceptive cues which are felt mainly within the individual himself. It can be pointed out that knowledge about the outside object can-not substitute for these proprioceptive cues, and that no information regarding social instrumentali-zation and operation of gadgets will ever answer the question of like, dislike, or fatigue. The pa-tient has to learn to tolerate cues which result from outside or inside interference (anger, anxiety, guilt, shame, fear, depression), and cues arising within the instincts related to biologic and social needs (36). Once he learns to feel these cues and tol-erates their presence without translating them im-mediately into either action or organ expression, the basis is laid for the learning of symbolic ex-pression.
Absence of symbolic expression limits the in-fantile personality to methods of interaction which are similar to those of baby or animal, and it is more than coincidence that infantile people pre-fer the company of children and dogs to that of adults. Social manipulation and control without corresponding symbolic expression is received by adult persons with caution. A manipulative ap-proach appeals to intuitive understanding and peo-ple frequently become defensive when these methods are used by adults. Frequently these approaches are primitive and undisguised, and infantile per-sons can then be compared to a threatening bull, a voracious mountain lion, a flattering cat, or a singing bird. In psychotherapy, then, the therapist has to be aware that nonverbal expression is the only means of communication which the patient understands. As therapy progresses, an attempt is made to connect verbal content and manipulative procedure. The patient has to learn to utilize words for the sake of expression rather than manipula-tion, and to abandon the use of words as sound without corresponding meaning.
This first phase of therapy is exclusively con-cerned with making the patient aware of himself as a psychologic and biologic entity distinct from the therapist; his actions are verbalized, his needs demonstrated, his reaction to interference acknowl-edged, and emphasis is placed upon the interre-lationship of these various phenomena. Once the patient accepts existence of himself as a separate unit, the next step can be initiated. The patient will, unfailingly, sooner or later start to ask the question "So what?" He will inquire how one can express feelings and how to use them. He will want to know what to do with anger, and other feelings once he does become aware of them. Now the mo-ment has come to point out the connection between feelings, affects, desires, needs, and subsequent ac-tion. Imitation, copying, and conformance have to be substituted by action, which is motivated by true needs and feelings of the patient. The indi-vidual's goals have to be worked out and separated from the aims of people he used to imitate. The in-direct reward of affection and pleasure sought from others has to be replaced by rewards found in the gratification of other needs. The most efficient in-strumental action has to be worked out for each individual's goal instead of using the approach taught by others. As time goes on, the patient then will institute new interpersonal approaches; he will gradually use experimentation and reality testing more and more.
This process of postnatal separation from the mother's body and soul should have been com-pleted within the first decade of the child's life. It is harder and tougher to go through the separa-tion belatedly, twenty or thirty years later, but it is not impossible. Before the separation can take place, however, the patient will and must estab-lish complete unity with the therapist. This sym-biosis gives the patient temporary strength and is usually achieved by means of ego-identification. The patient has to be permitted to copy, imitate, and function in conjunction with the therapist, and only as time goes on and very gradually can in-dependent action be initiated. Only through hard work does the patient gain his own identity, giv-ing up functioning in common with the therapist. The patient has to learn to be sincere in his self-expression and has to understand that one can ex-press subjectively what one feels without saying anything about the property of objects and phe-nomena of the environment. The patient learns to say "I hate" instead of "John Doe is nasty," and he will say "I feel anxious" rather than be en-gulfed in a number of anxiety alleviating activities. The patient will lose the fear of communicating and expressing verbally whatever is happening within himself as soon as he learns that self-ex-pression and feelings do not cause catastrophies, re-proach, and isolation. The patient will acquire the ability to express something about himself with-out at the same time interfering with others. In time, interpersonal relations will become less strained, because the patient begins to make sense to other persons who will react more pleasantly be-cause they will not feel attacked, threatened, and incorporated. When the foundations for this in-tegration have been laid the patient is either given vacation in terms of months or years in order to accumulate life experiences, or, the therapist pro-ceeds to shift die focus from self-expression to biographical study.
Only at this stage does the patient begin to understand the relationship of his past experiences to present situations. As he gives up the symbiosis and community of functioning with the therapist he simultaneously acquires his own identity by re-evaluating his biography within the therapeutic sit-uation. Up to now the outside world mattered, and only as he gains self-confidence, self-respect and in-dependence do past memories return and can the biographical material become integrated. Belatedly, then, the patient will attempt to utilize the con-clusions from early childhood experiences and in-stead of rebelling against traumatic events he will learn to accept past events as irretrievable and un-changeable.
The transference problem represents a particular issue in these infantile characters. One really can-not talk about transference because die concept implies preexistent though distorted interpersonal relations, which lead in the therapeutic situation to a systematic distortion in which therapist and pa-tient are in the fantasy of the patient assigned cer-tain roles. In the infantile character, however, the distortion introduced into the therapeutic situation is the result of uniform and stereotyped techniques and manipulations used with all people. It is an un-specific distortion (36), and, therefore, cannot be considered to represent a transference neurosis. In an organized neurosis the libidinous energy which previously went into symptom formation is in-vested into the transference neurosis. The infan-tile patient does not dispose of the necessary cues to experience complicated roles, and his main con-cern is directed to observing external cues which have a low organizing quality: the patient is not concerned with his role which originated in the family, but still asks basic questions such as who is more powerful, who is close or distant, and who is similar or dissimilar. Sometimes on an even lower level of organization he is interested in questions such as when, where, and how much of a response to make, who initiates action, and who is going to carry it out, which organizing principles should all have been learned in the first year of life but frequently are met for the first time in the con-tact with the psychotherapist. Once the necessary cues have been acquired and self-expression pro-ceeds on a symbolic level, a transference neurosis can develop substituting for organ or action lan-guage.
The infantile patient's attitude toward the ther-apist differs from the one observed in highly or-ganized neuroses. Since one of the reasons for im-maturity of the patient lies in the fact that in child-hood learning of roles was impossible, these ob-viously cannot be repeated with the therapist. Quite on the contrary, and as with the child, the learning of role and social function with the thera-pist is a first experience and therefore carries more reality value than is the case with more mature patients. The therapist must be explicit and even primitive in his procedure. He must express his own emotions so that the patient can learn; he must be a concrete figure—approachable, visible, understandable, and comprehensible. The therapeu-tic procedure is more one of learning than of rep-etition of single traumatic events, because the traumatic events accrued daily throughout the childhood of the patient. Gradually then does dis-tortion move in, which is based upon projection and acting out of imaginary roles which in childhood fulfilled a compensatory function.
If a true transference neurosis does not develop, what then are the effective agents in therapy with infantile characters? Consistency on the part of the therapist, his unconditional acceptance of the patient, and self-expression on the part of the therapist, create the necessary atmosphere char-acterized by continuity, and consistency, so that social learning is possible. Hence, the infantile pa-tient is able to establish his first consistent frame of reference, while the more mature patient tends to correct his frame of reference. The therapist can be considered as an ideal model, who at the same time has the possibility of using the patient's con-formist attitude and seeking of affection as a means of rewarding. Gradually the role of the therapist as an ideal model is abandoned and the patient transferred to a regime of learning through trial and error, which will lead to more independent action. Considering long-term progress one can see that at first there is an abandonment of the sham maturity by giving up play-acting and pre-tending. Thereafter the patient operates in close unity with the therapist and the therapist does child guidance with an adult. Afterward the in-dividual proceeds to progress and learns the mean-ing of roles. Compensatory fantasy material can be acted out in the therapeutic situation and sym-bolic self-expression is learned. Biographical analy-sis is later used to connect the childhood experi-ences with present-day experiences, thus inducing the patient to make peace with his childhood.
Summary
Personality structure, interpersonal relations, and rehabilitation of the infantile person have been described as encountered in clinical medicine in a variety of psychosomatic conditions.
Mature persons differ from the infantile per-sonalities by having at their disposal suitable tech-niques for interpersonal relations and by having mastered problems of communication in terms of self-expression and self-extension, thus availing themselves of expressive signs which are derived from the somatic sphere, from action, and from verbal symbolization. In contrast, the infantile person does not possess the necessary techniques for social interaction and communication; hence life experiences cannot be integrated. In the ab-sence of satisfactory interpersonal relations com-munication is limited; signs used for self-expres-sion originate in the somatic sphere or are related to action, and interpersonal relations on the level of verbal symbolization are rudimentary or non-existent.
Personality disorganization and specific disability for interpersonal relations are factors which tend to expose the immature personality repeatedly to frustrating situations, the management of which is attempted by means of control rather than through mastery and adaptation. Inasmuch as op-eration through control is not likely to be successful in the long run, the infantile person is frequently confronted with emergencies. Although both ma-ture and immature persons tend to handle emer-gency situations by means of physical symptoms, the mature person reverts only temporarily to somatic expression, while in the immature per-sonality this type of expression persists.
Inasmuch as the infantile personality is incapa-ble of removing sources of frustration through goal-directed behavior and, in addition, is unable to ex-press excess tension in interpersonal relations, ten-sion must be expressed either through action or through organs. If tension is managed through ac-tions which are intended to alleviate tension, pathol-ogy can develop incidental to activities, as one can see in obesity through overeating, in accidents through overexposure to danger, or in venereal dis-ease through promiscuity. If tension is expressed in somatic terms it is related to vascular, respiratory, intestinal or skeletal pathology. It is this peculiar coincidence of emergency management by means of somatic expression with the habitual expression of tension through organs or action which makes infantile personalities so liable to psychosomatic conditions.
Since the psychotherapeutic methods employed in the treatment of psychoneuroses were derived from study of more mature and organized per-sons, the rehabilitation methods used with psycho-somatic patients and immature persons had to be modified. In such cases, the therapeutic situation constitutes really the first experience in consistent human interaction. The whole approach can be summarized by stating that the procedure is really child psychotherapy with chronologically adult pa-
