Clinical Excerpts

Prior to the rise of behavior therapy,¹ it had been axiomatic in psychotherapeutic and psychoanalytic circles that if a symptom is removed without touching the underlying conflict, there remained strong likelihood of developing a new symptom in place of the old. Lazarus² quotes Friedman³ as typifying this view: “As long as the underlying conflicts remain untouched and unconscious, the patient is prone to develop a new phobic symptom in place of the one removed.” The issues are complex, but behaviorists are prominent among those proposing lack of evidence to support this analytically derived notion.⁴, ⁵ The following case study is presented as evidence in favor of the hypothesis of symptom substitution.

A thirty-five-year-old delivery man entered treatment for a paraplegia of two weeks’ duration. Nine months earlier (July 1973) his panel truck hit a puddle and overturned, rendering him unconscious. His first thoughts on “coming to” were of “what would happen to my wife and baby if I die or am paralyzed.” By X ray it was determined that he had sustained slight compression fractures of three lumbar vertebrae (Freud's “somatic compliance”⁶). He was hospitalized for approximately six weeks, receiving physical therapy. He left the hospital ambulatory in late August, and stayed home for over two months “at my doctor's advice,” incurring his wife's abuse for not working. He began having sexual problems. Although his wife had previously been “frigid,” shortly before her husband's accident she had agreed to have intercourse more often; paradoxically, the patient began losing desire, blaming this on his “aching back.” In late November he returned to work, but after one month began having fifteen-minute episodes of morning paraplegia, occasionally accompanied by fecal or urinary incontinence, but without sensation loss. By the turn of the year , he was experiencing severe nonradiating pain in the lower back, which necessitated his job resig