As a general summary of this study it would appear that we can postulate a larger setting to the phobia than the grief inspiring experiences attending her mother’s death. The unconscious complex included the belief that she was to blame and the sentiment of self-reproach, and the whole gave a fuller meaning to the ringing of bells in a tower. The fear besides being a recurring association was also a reaction to the subconsciously excited setting of a fancied truth or self-accusation. Although excited by towers and steeples the fear was really of self-reproach. Towers, steeples, and bells not only in a sense symbolized her mother’s death, but her own fancied fault. It was in this sense and for this reason that she dared not face such objects. The conscious and the unconscious formed a psychic whole.[[190]]
Now in reaching these conclusions see how far we have traveled: Starting with an ostensible phobia for towers, we find it is more correctly one of ringing-of-bells, but without conscious association; then we reach a childhood’s tragedy; then a self-reproach on religious grounds; then a belief in a fault of childhood’s behavior culminating in a lifelong self-reproach—the causal factor and psychologically the true object of the phobia: and between this last self-reproach and the phobia no conscious association.
The therapeutic procedure and results are instructive. As the fear was induced by a belief in a fancied fault exciting a self-reproach, obviously if this belief should be destroyed the self-reproach must cease and the fear must disappear. Now when all the facts were brought to light, the patient, as is usual, recognized the truth of them. She also recognized fully and completely the real nature of the fear, of the self-blame and of the self-reproach. There remained no lingering doubt in her mind, nevertheless the bringing to “the full light of day” of all this did not cure the phobia. As the first procedure in the therapeusis it was pointed out that it was contrary to common sense to blame herself for the heedlessness of a child; that all children were disobedient; that she would have been a little prig if she had been the sort of a child that never disobeyed, and that she would not have blamed any other child who had behaved in a similar way under similar circumstances, and so on. She simply said that she recognized all this intellectually as true and yet, although it was the point of view which she would take with another person in the same situation, it did not in any way alter her attitude toward herself. In other words the bringing to the full light of day of the facts did not cure the phobia. It was necessary to change the setting of her belief. To do this either the alleged facts had to be shown to be not true or else new facts had to be introduced which would give them a new meaning. This, briefly told, was done in the following way:
She was put into light hypnosis in order that exact and detailed memories of her childhood might be brought out. Then, through her own memories, it was demonstrated, that is to say, the patient herself demonstrated, that there was considerable doubt about her having had phthisis at all; that she was not taken to the usual places of “cures” for phthisis but sojourned in the gay and pleasant cities and watering places of Europe; that her mother really staid in Europe because she enjoyed it and made an excuse of her daughter’s health not to come home; that she might have returned at any time but did not want to do so; and that the fault lay, if anywhere, with her physician at home. When this was brought out the patient remarked, “Why, of course, I see it now! My mother did not stay in Europe on account of my health but because she enjoyed it, and might have returned if she had wanted to. I never thought of that before! It was not my fault at all!” After coming out of hypnosis the facts as elicited were laid before the patient; she again said that she saw it all clearly, as she had done in hypnosis, and her whole point of view was changed.
The therapeutics, then, consisted in showing that the alleged facts upon which the patient’s logical conclusions had been based were false. The setting thereby was altered, and a new and true meaning given to the real facts. The result was towers and steeples no longer excited fears, the phobia ceased at once—an immediate cure.[[191]]
Type D. In this type the conscious psychosis consists of idea, meaning, affect, and physical disturbance. F. E. suffered from attacks of so-called “unreality” accompanied with intense fear. She was unable to give an intelligent explanation as to why she was afraid of the attacks—harmless in themselves—until it was brought out that there was in the background of her mind the thought that the attacks spelled insanity (or that she was likely to go insane) and also death. Following the attacks there was amnesia for these thoughts. Her fear really, then, was of insanity and death. The content of consciousness in the attacks contained the perception of herself as an insane person, thoughts which expressed the meaning of her attacks, and fear. (The usual physical disturbances of course accompanied the fear.) No amount of explanation of the harmlessness of the unreality syndrome sufficed to change her point of view, i.e., its meaning to her. But going further it was discovered that her self-regarding sentiment and her ideas of insanity and death were organized with a large number of fear-inspiring antecedent experiences which explained why she regarded the attacks as dangerous to her mentality and life; and why the biological instinct of fear was incorporated with the self-regarding sentiment. These experiences had long passed out of mind and there was no conscious association between them and her phobia, but they could be recalled as associative memories.[[192]] The unreality attacks had for her two meanings which were within the content of consciousness, viz., 1, insanity, and 2, death. The first was derived from (a) antecedent girlhood and later experiences which had engendered the unsophisticated belief that having the mind fixed on one subject, as was obtrusively and painfully the case at one time, meant insanity: and (b), from the fact that the bewildering, irreconcilable, absurd thoughts, conflicts, and emotions in which the unreality attacks culminated meant insanity.
The second meaning (death) was derived from (a) the previous fixed idea (just referred to), organized with that of insanity—namely, an unsophisticated medieval idea of hell which was conceived of as the equivalent of death and which had excited an intense horror of both; and (b) from the fact that in the unreality attacks there was a struggling for air; struggling was in her mind, the equivalent of convulsions;[[193]] convulsions of unconsciousness; and unconsciousness of death. All these various ideas and the intense fears which each gave rise to had become organized into a complex, and, in consequence of these antecedent experiences in which self took a prominent part, the instinct of fear—as I conceive the matter—became incorporated within the self-regarding sentiment. (Anything that aroused this sentiment tended to arouse the emotion of fear, as in another person it would tend to arouse the emotion of pride, or self-abasement.) At any rate this organized complex was the setting which gave the meaning to her phobia. There can be, I think, no manner of doubt about this. The patient herself explained her viewpoint through these ideas here briefly summarized. The only question is as to the mechanism of the phobia. Now as Type D, of which these cases are examples, differs clinically from the preceding three types only in the addition of one more element—meaning—to the conscious psychic whole, a consistent interpretation would seem to compel us to postulate also a functioning subconscious complex or setting and in this case of the antecedent experiences disclosed as a factor in the mechanism and a part of the psychic whole. Out of this complex emerged into consciousness the idea of insanity and death and fear as the meaning of the unreality syndrome, the whole constituting the phobia psychosis.
That there was in fact a subconsciously functioning process derived from this complex would seem to be almost conclusively shown by another phenomenon manifested. I refer to the vivid visualization of herself in a convulsion, struggling for air and manifesting fright, which she experienced in each attack. We have seen that such a visualization (i.e., a modified vision) is the expression (secondary images?) of a subconscious process (co-conscious ideas?). As a matter of fact this particular visualization was a pictorial representation of antecedent thoughts organized with thoughts of death and insanity and still conserved in the unconscious. We must believe, then, that it was these antecedent thoughts (in the first place her apprehension of inheriting Bright’s disease and convulsions from her father, and in the second place her conception of the unreality syndrome as a state which might possibly end in convulsions) which, functioning subconsciously, induced the quasi hallucinatory expression of themselves.[[194]] It is difficult to get away from the conclusion that the remainder of the setting from which the ideas of insanity and death were derived also functioned as a subconscious process. Whether this process was conscious or unconscious is a secondary question which we need not consider.
In weighing the probabilities of this interpretation we should bear in mind that there were two conscious beliefs of which the patient was fully aware and which were very real to her; namely, the liability of becoming insane and to convulsions and death. The conative force of the instinct of fear linked to such ideas is quite sufficient to drive them to expression when out of mind and subconscious. Or expressed differently we may say that the fear was a reaction to these ideas which the patient dared not face.
We ought not, however, to be too sweeping in our generalizations and go further than the facts warrant. We are not justified in concluding that the linking of an affect to an idea always includes a subconscious mechanism. On the contrary, as I have previously said, probably in the great majority of such experiences, aside from obsessions, no such mechanism is required to explain the facts.