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This chapter will endeavor to further interpret the clinical material in terms of psychodynamic theory. Utilizing my psychiatric training background, I have employed psychoanalytic concepts as the main framework of reference in trying to understand these patients. Cultural idiosyncracies, however, modified these formulations to the extent that a rigid application of psychoanalytic theory became untenable. While constantly keeping the theory in mind, I had my eyes, ears, and other sensory receptors attuned to the culture. Also, while it was possible to carry out a coordinated and understandable system of translating Filipino behavior in terms of both pschodynamic theory and cultural assumptions, the task of deciding which of the two bore greater relevance to a given segment of behavior was, in some situations, extremely difficult to assess. The matter was often decided simply on an empirical basis in the clinical management of and psychotherapeutic experience with the patient.
There is no single touchstone in interpreting peoples’ behavior or their emotional reactions. Many workers object to psychoanalytic theory because it is too neat and even too naive a scheme; it tends to explain everything. With the current emphasis on social and cultural processes, a social psychiatrist or social psychologist nowadays may formulate his interpretations of patients’ conflicts in terms of social and cultural dynamics and include little, if any, of the, psychoanalytic theory. On the other hand, there are those who feel, to use one colleague’s words, that “people have the same hang-ups everywhere.” The mere fact that a group of patients belong to one racial or cultural category does nor warrant preference for one single set of dynamics over another. At all times one is compelled to take both psychological and cultural forces into consideration.
As is true everywhere else, each of the patients in this study was unique and different from the rest. Each one’s predicament represented his own personal mixture of psychological, cultural, and social sets. The only common denominator was the presence of conflict, distress and/or dysfunction.
In the study and analysis of factors which generated stress in these patients, it was essential that a reasonably comprehensive history of each one’s psychological upbringing be obtained. At the same time, understanding the present illness and deciding on the form and direction of clinical management was often an urgent matter. For this latter purpose, a prompt assay of current relationships, and of the patient’s ready, as well as potential, abilities to cope with planned psychiatric intervention, had to be made.
From these combined surveys of both his past and present psychological life (and by psychological I include all factors which contribute to it, whether it be constitutional or environmental) came data which were characterized by a striking recurrence of certain themes and patterns. These were reflected not only in the symptoms presenting illnesses, in the histories of interpersonal relationships, in behavior patterns, and in fantasy life but also in various aspects of the doctor-patient relationship.
Without detracting from the uniqueness of each patient and his particular illness, I have picked out these themes for a theoretical conceptualization of the underlying psychodynamic processes. Some of these may have been gleaned from the previous sections on symptomatology and areas of conflict.
A simple diagram giving at a quick glance the interrelation of these recurrent dynamic themes is shown below. Each one is a site of psychopathology, representing an area of ego weakness. The pathways shown by the arrows indicate the general directions of pathogenesis. The diagram is over-simplified as one can readily see. For example, the backward flow of processes, such that the resulting pathology often reinforces the original disturbance, is not indicated. Thus, the conflict areas generated in men and women can reinforce and entrench further the dependency problem. In addition, conflicts between men and women, with already compromised segments of their personalities entering into further incompatible interactions, will give rise to other forms and pathways of pathology.
The diagram, therefore, can only serve as starting point for discussing very varied and complicated psychodynamic processes which, in the ultimate analysis, cannot be quite the same for two patients, even if many aspects of one bear similarity to the other.
(1) Passive, feminine wishes
(2) Blocked Aggression
(3) Success-failure conflict (Castration fears?)
(1) Separation Anxieties (Object-loss problems)
(2) Blocked Aggression
(3) Sexual Distortions (Fear, Shame, Disgust, etc.)
Ambivalence was a key conflict in these patients. It was present in practically every sphere of the patient’s emotional life, but most glaringly manifested at the height of the illness. As the illness subsided, the ambivalence retreated behind repressive or rationalization defenses. In the character neuroses wherein no acute episode brought the ambivalence to awareness, patients remained complacently convinced that there were no contradictions in their attitudes and actuations.
These three themes—unresolved dependency, deficient autonomy, paralyzing ambivalence—are seen and described in patients from other cultures. In this group of Filipino patients, the psychological background as well as the nature of the emotional conflicts underscored them even more so. They were vividly illustrated especially in the current, ongoing relationships of the patients. The nature of these relationships represented a clear extension or continuation of what had been experienced in the past.
Prolonged dependency in the form of continuous nurturance and protection inevitably conditioned the person to a state of impaired autonomy. The majority of these patients, particularly a large percentage of the women and of the adolescent boys who regressed in the face of challenge, had never experienced what F. H. Erikson calls “the whole critical alternatives between being an autonomous creature and being a dependent one.” He continues:“And it is not until then that he is ready for a decisive encounter with his environment, an environment which, in turn, feels called upon to convey to him its particular ideas and concepts of autonomy and coercion in ways decisively contributing to the character, the efficiency and the health of his personality in his culture.” (Erikson’s italics)
Crossing the crucial boundary from dependency into the beginning of a sense of autonomy would have accomplished two things. It would have paved the way toward self-assertion, self- expression and eventual mastery of one’s aggressive impulses. It would also have provided the individual a more permanent kind of self-esteem, nurtured by parental acceptance and encouragement, but ultimately derived from the resources of the self. In these patients, both goals had been compromised by the inordinate dependency.
Patients who seemed to exemplify successful achievement of a sense of autonomy and mastery accomplished only a superficial renunciation of dependency ties mainly through relentless reaction- formation mechanisms. Self-sufficient, independent, ambitious—and in many businessmen and executives, cold and calculating as well— seemingly autonomous individuals appeared frightened at the slightest evidence in themselves of a return to a dependent position.
In both types of patients—those who openly regressed to being helpless and those who fought the impulse to regress—the result was a state of ambivalence, which remained unresolved so long as the dependency-autonomy problem was merely played around with, through denial, repression, displacement, and rationalization, but had never really been brought out in the open and worked over. This state of ambivalence ramified into other areas involving other relationships and other activities. Thus, relationships had to be reaffirmed continuously; physical separations became a serious threat to severance of ties.
At the same time, relationships were constantly threatened by disturbing wishes to break away or to hurt back or to give only to oneself. In women, relationships were hampered by an inchoate realization of what a mature woman is. Sexual wishes, half-denied and half-disturbed, sought gratification. Blocked by fear and a sense of inferiority, as a woman, they attained expression only in less mature and sometimes infantile forms.
Such extent of ambivalence cannot but bring pre-Oedipal experiences to task. In the earliest phase of the mother-infant relationship, the central act of breast-feeding was, to the infant, both libidinal and aggressive. Libidinal, in the sense of infinite closeness, such that two egos, as it were, were pleasurably merged into one; aggressive, because the act itself was devouring and incorporative. One possesses one’s love object by destroying and swallowing to make it part of oneself, Identification during the oral stage is an ambivalent one but “united in one act.”
In the next phase, referred to as the anal, where the principal event is the first attempt at self-mastery or autonomy, these two effects of love and hate are split. Wanting yet rejecting, building and destroying, hurting then consoling, are repeated in cycles. Here the ambivalence attains new heights as the growing child aggressively reaches out, grabs, holds, destroys external objects.
In the Oedipal state lies the hope of reconciling these ambivalent poles. This marks the initiation of the child into relationships with external objects, which are desired for themselves. The self-satisfying possessiveness, jealousies, resentments, destructive impulses of the earlier infantile stages are neutralized in what Freud calls “the fusion of the instincts.” The libidinal instincts successfully render the aggressive impulses inert.
As Herman Nunberg (1)51) puts it:
That the object, after fulfilling its task, psychically ceases to exist for the infant is perhaps due to the fact that at this age only one active organ, the oral apparatus exists for both libidinal and aggressive strivings in a single act two opposing instinctual aims are gratified. At 41 stages of development we encounter such a contrast of the instinctual aims. This contrast is called “ambivalence.” In the oral phase, it seems to appear united in one act.
The anal-sadistic phase is the one in which ambivalence is most evident. Here every libidinal desire coincides with aggression and the will to destroy; every positive impulse is accompanied by a negative one, to such m extent that frequently the positive impulse can appear only in the form of the opposite, for instance, beating has the meaning of “loving.” In the next phase, the infantile-genital or phallic phase, ambivalence expresses itself in the existence, side by side, of the opposites, love and hate. Not only is the emotional life split in two, but also concepts and ideas are accompanied by their negatives.
In observing the development of object choice, one notices that the destructive instincts and hatred gradually recede in favor of love, Eros. Ambivalence, the manifest expression of the simultaneous negation and affirmation of the objects of the external world, decreases slowly to give way finally to a more or less unified, positive attitude toward the love objects.
Eric H. Erikson pinpoints the anal stage as the decisive (italics mine) arena for the resolution of ambivalence.
This stage, therefore, becomes decisive for the ratio between love and hate, for that between cooperation and willfulness, and for that between the freedom of self-expression and its suppression. From a sense of self-control without loss of self-esteem (Erikson’s italics) comes a lasting sense of autonomy and pride; from a sense of muscular and anal impotence, of loss of self-control, and of parental over-control comes a lasting sense of doubt and shame.
Here Erikson brings in his concept of the painful state of shame at the child’s discovery of his weakness, shame to be later on re-experienced, countless times, particularly in a culture where shaming “is abundantly utilized in the educational method.”
Impaired autonomy then leads to defective systems of self- control, which brings alternating moods of helplessness and rage. At the same time, the failure of the love and hate instincts to fuse leaves unassimilated large residues of ambivalence and jeopardizes the erection of a solid sense of self-esteem. The person views himself with the same ambivalence and cannot completely accept himself with confidence.
The Oedipal experience, in asking the child to renounce the parent (of the opposite sex) as a love object and to find one of his own, is a psychological milestone for two reasons. It is the first lesson in renunciation and separation. By finally detaching himself psychologically from his parents, he gives up his infantile love for them for a more mature, objective kind. He begins to see himself and each parent as separate entities; each one is accepted and loved as he is, with all the “good” and the ‘bad” in each. This marks the end of the “all or none” relationship of the undifferentiated infantile ego to the nurturing mother. It marks the end of the splitting of the love object into the “good” mother, who is internalized arid the “bad” mother who is projected into the hostile world. It marks an end to the over-compensatory love and idealization during the anal period.
When he successfully negotiates this, the individual learns to love unambivalently, freely, without unrealistic guilt or coercive sense of obligation. If for reasons of previous psychological fixations as well as difficulties during the Oedipal phase, the growing individual fails to accomplish this end, parental and all future love relationships will reflect the insecurity from unresolved ambivalence.
Ernest Becker (1962), who has unrestrainedly and eloquently criticized Freudian theory as well as its various applications, does allow that the Oedipal experience marks “the crucial change in behavior.” In his book The Birth and Death of Meaning, he underscores the transition of the child during the Oedipal phase from concrete body symbols to mental symbols which he will then use in transactions within a social world. His remarks have topical relevance to Filipino patients not only because he describes Oedipal events in a social context but also because he emphasizes the importance of replacing body symbols, which task the Filipino patient finds difficult to accomplish. He says:
The situation can become quite involved, and does. Remember that the child is being edged by the mother away from his utterly dependent biological relationship to her. At the same time, he is attempting to relate to both objects in a manner which makes him most acceptable to them. The crux of the confusion is that he is not yet a fully symbolic animal; be has learned to relate using primarily his body for cues. This is what we mean in one sense when we say that the child tends to concretize his experience: the world and life reflect in his own body, to use Paul Sc.hilder’s phrase, since this body is the coin with which he has been so successfully transacting his love relationship to the mother. As he is being edged out of paradise and urged to new mastery, we would expect him to be alert to his body, and to the bodies of the adults, for cues by which to maintain a solid relationship, and perhaps even a new kind of mastery, one which is comfortably concrete, like those of the past, rather than strangely symbolic.
The ultimate frustration of the child is that the parents will, of course, have none of this.... (He then) abandons his seductive intentions, and seeks to function in an entirely new way: performing according to the ideas and values of his parents, and getting his satisfaction in this way, rather than getting it in the formerly direct physiological way. This is the “resolution of the Oedipus complex,” and the internalization of the “superego.” The parents’ values become the touchstone for the child’s conduct. He has sacrificed a close, concrete physiological relationship for the rewarding performance of a distanced, self-contained symbolic functioning. He now gets approval for a new kind of mastery, and a symbolic member of society is fashioned. In Adler’s terms, a successful Oedipal transition awakens an individual who has social (symbolic) interests rather than personal (body) interests.
The Oedipal transition is complete when the child exchanges erotic rewards for the reward of functioning symbolically in the values of the parents. When the child finally internalizes these values without needing an erotic “crutch,” so to speak, the implanting of the superego is complete. The child says, “You no longer have to punish me, Father; I will punish myself now.” In other words, “You can approve of me as you see how well I do as you would wish me to…….
Some Oedipal transitions have been colossally bungled: there are parents who really do not want to or cannot create an independent, symbolically functioning animal. The closeness of an irresistibly endearing object may be painfully missed by a lonely adult. There are any number of reasons why psychoanalysis remains, par excellence, a theory of neurosis, a theory of constricting learning which occurred during the Oedipal transition.
Another recurrent finding among these patients is an abundant narcissism, obviously another by-product of the earlier experiences. The narcissism has certain qualities. Its most obvious feature is an unabashed need for personal attention, approval and love. This is expressed sometimes directly in words as a frank affirmation of their need. At times, it is indirectly expressed, in negative terms as fear of being deprived of this gratification. Thus, they keep referring to themselves as “sensitive,” “easily hurt,” “don’t want to make the first move, because I may get hurt.” More than words, the behavior conveys this need eloquently.
A second feature of this narcissism is the facility with which the body is used to express it. There is much attention to the body appearance and body movements. Body language tends therefore to be highly developed. A gesture, exchange or symptom involving the body can gratify libidinal needs and hold aggressive impulses in abeyance more than words can. Physical demonstrations of affection, e.g., touching, stroking, or merely being physically present or close, are eagerly sought. Likewise, low threshold for body pain becomes the rule.
The need for personal attention, approval, and love may be understood psychoanalytically as an inordinate need for external narcissistic supplies. The libidinal striving is directed primarily towards objects in the external world. Every instance of approval by the ego-ideal is followed by a feeling of being loved.
The body language appears to have been conditioned by two factors: firstly, the long-standing gratification through body contact with relatives and parental figures, especially mother; and secondly, the suppression and repression of certain feelings predispose to expression through somatic means and where these feelings are concerned, to an emphasis on non-verbal communications. Patients recall how particular parents were about motility and body cleanliness. Although toiler training is quite permissive, parents restrict movableness and have especially demeaning names for a girl who moves too much or is disorderly with one’s posture, dress, or belongings. Many a patient recalled being the burara” (as mother put it) of the family.
One must note, however, that although these findings are the particular psychological needs in these patients, the culture itself encourages the manifestations of these tendencies. Thus, physical health is generally a prime concern of everyone; it is apt to be the end-all and be-all of all possible earthly blessings. Physical looks are the first object of attention and comment in a person. The need for acceptance and affection are primary. A tagalog word “lambing” denotes widely employed overtures for, as well as manifestation of, affection which are deemed lovable in a person, regardless of age or sex. The well-adjusted person in the culture is one who admittedly seeks affection and is able to evoke it from others.
The sets of conflicts listed under each sex group indicate those most frequently encountered. A patient may illustrate one type of conflict more than the others. Each patient presents his own unique mixture, giving it his particular symptom signature. These categories when taken broadly will include all related conflicts. The following discussion will attempt to specify each of the conflicts and their pathogenesis.