The Man Who Was So Pissed Off He Couldn't Pee: Anxiety, Anger, and Identification with the Aggressor

The following article by Michael Vannoy Adams is a presentation delivered at the conference of the Object Relations Institute for Psychotherapy and Psychoanalysis, New York, April 9, 2005.

Anna Freud is not known for being an object relations psychologist. It is her nemesis, Melanie Klein, who enjoys that reputation. Anna Freud is known for being an ego psychologist. The title of her famous book is The Ego and the Mechanisms of Defense - not Object Relations and the Mechanisms of Defense.

Anna Freud is not interested in the relations between internal objects, as Klein is. She is, however, interested in the relations between the ego and external objects - and, at least to that extent, she is an object relations psychologist. She has a special interest in the mechanisms that the ego employs to defend itself "sometimes against an internal force and sometimes against an external force" (1966: 109). For Anna Freud, the internal forces against which the ego defends itself are not internal objects but instincts, or drives. In contrast, the external forces against which the ego defends itself are, she says, "external objects which arouse its anxiety" (1966: 110).

The title of one of the chapters in The Ego and the Mechanisms of Defense is "Identification with the Aggressor." For Anna Freud, identification is a defense mechanism. More specifically, it is a mechanism that the ego employs to defend itself against external objects. To illustrate this process, Anna Freud cites the example of a child who undergoes an anxiety experience. The child experiences an external object, an aggressor who arouses the ego's anxiety. The external object is an anxiety object against which the child's ego defends itself by identifying with the aggressor. Anna Freud describes the process of identification as an impersonation:

A child introjects some characteristic of an anxiety object and so assimilates an anxiety experience which he has just undergone. Here, the mechanism of identification or introjection is combined with a second important mechanism. By impersonating the aggressor, assuming his attributes or imitating his aggression, the child transforms himself from the person threatened into the person who makes the threat. (1966: 113)

Identification with an aggressor in childhood may persist into adulthood with serious consequences.

Such was the case with a 38-year-old man who entered Jungian analysis with me. He could not "relieve himself," and he hoped that I might be able to relieve him. The man had called in sick to work. He had a bladder infection. It was "scary," he said. It was "hard to pee," and that made him feel "like an old man." In an effort to diagnose his urination problem, he had undergone a cystoscopy. The urologist, he said, had "stuck a tube up my penis." The problem had started a couple of years earlier. At work the restroom was not conveniently located. He would need to urinate, but because the restroom was so far away, he would delay going. He got an infection. It went away after awhile, but the problem had gotten worse in the last year when he had been under stress at work. He was tense, and he could not urinate when he needed to. "To tell you the truth," he said, "I don't remember when it started." His prostate was slightly enlarged but not abnormal. The problem was exacerbated in the days after he had sexual intercourse. The urologist had told him that sexual intercourse "more or less makes the prostate irritated." He was trying to drink more water, but it did not seem to get him hydrated enough to urinate. He was taking a muscle relaxant and seeing an acupuncturist.

If this was simply a physical problem, it would presumably have a physical solution, and a urologist could cure the man. Now, however, he had consulted me - and I was not a medical doctor, much less a specialist in urology. I was merely a psychoanalyst - and, worse, a Jungian analyst. Freudians know all about penises, but Jungians? And what do Jungians know about urination?

Dreams sometimes depict difficulty in urination, as, for example, this dream does:

I'm at a urinal. I'm having an extremely hard time pissing. It just won't come, no matter how hard I strain. I press my head against the cool tile wall. I can piss more easily. A stream starts to come out.

As I interpret this dream, I infer that the dreamer has a hard time pissing because he is a "hothead," for when he becomes a "coolhead," he has an easier time pissing. With exquisite exactitude, this dream specifies the solution to the problem. In this case, the unconscious provides an image that precisely informs the dreamer what would be necessary for urination to occur spontaneously and autonomously - a cool head (or ego).

Jungian analysts do, in fact, know about urination. For example, Edward C. Whitmont says that "the urinary experience represents a yielding to or controlling of an outgoing libido stream" (1969: 243). Whitmont elaborates:

The ego learns to choose between allowing the outpouring to pass or withholding it. The choice between controlling or yielding to emotion and affect is thus invested in the ego. The control of the urinary function (the goal of toilet training) incorporates the necessity for restraining one's urges, needs and desires in deference to an ideal which the ego experiences as superordinated to itself. (1969: 243)

According to Whitmont and Sylvia Brinton Perera, "Urination, as image, depicts self-expression by virtue of yielding to or allowing the flow of what needs to come through one" (1989: 146). Whitmont and Perera say that the image of urination "has to do, then, with the letting go or allowing of emotion, or of its inhibition, when, for example, one dreams of urgently having to go and holding it back" (1989: 147).

My patient knew that the problem was not physical but psychic. "I'm holding myself back," he said, "not letting myself go" - and he did not just mean not letting himself go to the bathroom. He meant not letting himself go emotionally. "I'm afraid," he said, "that if I let myself go, I'll blow someone away. I'm afraid that I'll kill someone - or myself. I get really angry at guys who are trying to get on the subway when I'm trying to get off. I pushed one guy and pinned another guy against the wall. The other day a bodybuilder was walking down the street toward me, and I suddenly wanted to pick a fight with him. My dick got really tense. I noticed that at the time."

At that point, I said to my patient: "You're pissed off."

From a Jungian perspective, anger is one of many vital human instincts, or drives. As I regard anger, it is not absolute. It is not intrinsically either bad or good. Whether anger is bad or good is relative to whether it is repressed or how effectively it is expressed.

My patient's problem was anger - whether to express it and, if so, how to express it. His bosses had expressed their anger in an active-aggressive way. "My current boss," he said, "even fucked over his own brother. They used to get into fist-fights at work. My boss feels that everybody's out to fuck him, so he tries to fuck them first." These are linguistic usages in which a sexual word - which Leo Stone calls "the principal obscene word of the English language" (1984) - is employed for an aggressive purpose.

Jonathon Green says that to "fuck over" another person means to "harm," "beat up," "hurt emotionally," "act cruelly," "interfere," or "mess around with" that person (1999: 456). To fuck over your own brother is to engage in an aggressive act that is not only implicitly homosexual but also incestuous. To fuck other people before they fuck you is a preemptive strategy and tactic, what I might call a "penile-sadistic" defense mechanism. From an object relations perspective, this is a regression to what Melanie Klein calls the "urethral-sadistic" stage. Klein says: "The data I have been able to collect from early analyses reveal that between the oral-sadistic and anal-sadistic stages there exists another stage in which urethral-sadistic tendencies make themselves felt" (1975: 253).

In his previous job, my patient's boss had been an alcoholic who had thrown tantrums and had verbally abused one employee so badly that, in my patient's opinion, the employee, who was HIV-positive, had died from the stress. He would quake in his chair, turn blue with anger, and scream at my patient. This verbal abuse evoked childhood memories of physical abuse. As a child, my patient had been beaten up not only by other boys but also by his father, who had a bad temper. His father had tossed him across the room at age three and had hit him with his fist at age 13.

My patient employed a passive-aggressive defense against his bosses. He had a way of making his bosses think that it didn't bother him. He would answer them calmly. He would, however, also give them a look, a stare. "Bosses don't look me in the eye when there's a confrontation," he said, "but I have a way of staring them down."

My patient was trying, he said, "not to piss anyone off." He was unable to express his anger effectively. Instead, he repressed it. My patient was pissed off at everyone, but he was trying not to piss anyone off. Rather than let his anger out, he was holding it - and his urine - in. He was so pissed off that he couldn't pee.

How might I interpret this case from a psychoanalytic perspective - and, more specifically, from an object relations perspective? It seems to me that this is a case of the ego identifying with an aggressor. Etiologically, my patient's anger derived originally from his anxiety experience as a child when his father physically abused him, tossing him across the room and hitting him with his fist. As a child, he was unable to defend himself physically. To defend himself psychically, he identified himself with his father, the aggressor. In this process, he introjected and impersonated his father. The external object, the aggressor, became an internal object with which his ego identified.

Subsequently, when his bosses verbally abused him, my patient experienced them as aggressors who evoked the memory of his father as an aggressor. His anger was extreme. It was homicidal or suicidal. Rather than express his anger in an effective, active-aggressive way - for example, verbally - he repressed it and then expressed it nonverbally, in a passive-aggressive way. In a return of the repressed, my patient's anger was converted, hysterically, into a physical symptom - difficulty in urination. Controlling his anger was embodied, symptomatically, as controlling his urine. At work, there was an "if-then" logic to this symptom, for, by definition, a "boss" is a person who exercises hierarchical control over workers, and, as a worker, my patient was most definitely not in control in that environment. If my patient could not control his bosses because they controlled him, and if he could not control his anger, then he could at least control his urine.

Diagnostically, this was a case that combined what the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) calls, provisionally, "Passive-Aggressive Personality Disorder" and what it calls "Conversion Disorder." The DSM-IV says that the essential criteria for Passive-Aggressive Personality Disorder are "negativistic attitudes and passive resistance," which occur "most frequently in work situations," especially in relation to "authority figures" (American Psychiatric Association 1994: 733). It says that the essential criteria for Conversion Disorder are "symptoms or deficits affecting voluntary motor or sensory function that suggest a neurological or other general medical condition" but that, in fact, indicate a psychological condition, with the symptoms or deficits "preceded by conflicts or other stressors." Among the symptoms or deficits in Conversion Disorder, the DSM-IV specifically includes "urinary retention" (American Psychiatric Association 1994: 452).

In Studies on Hysteria, Freud discusses the case of Frau Caecilie, who "suffered among other things from an extremely violent facial neuralgia" (1893-1895), SE 2: 176). Freud says that he was "curious to discover" whether the cause of this physical symptom was psychic (1893-1895), SE 2: 178). He summarizes the analysis as follows:

When I began to call up the traumatic scene, the patient saw herself back in a period of great mental irritability towards her husband. She described a conversation which she had had with him and a remark of his which she had felt as a bitter insult. Suddenly she put her hand to her cheek, gave a loud cry of pain and said: 'It was like a slap in the face.' With this her pain and her attack were both at an end. (1893-1895, SE 2: 178)

According to Freud, "She felt as though she had actually been given a slap in the face." A physical symptom, Freud says, is formed when a verbal expression is taken literally and hysterically converted into "a somatic expression" (1893-1895, SE 2: 180). The hysteric, he says, takes "a verbal expression literally." By a verbal expression, Freud means a figure of speech - for example, a "slap in the face" (1893-1895, SE 2: 181). In effect, the hysteric literalizes and, in a sense, "somatizes" a metaphor. In just this way, my patient literalized a metaphor. He was angry - or, in the vulgar figure of speech, "pissed off." He tried, however, "not to piss anyone off."

The word "piss" is a verb that derives etymologically from the Middle English pissen, the Old French pissier, and ultimately (it is assumed) the Vulgar Latin pissiare. "Piss" is considered a vulgar word, like those that Ernest Jones says are often repressed into what I might call the "linguistic unconscious" and are then replaced by a euphemism that is considered more proper. According to Jones, "The process in question can often be followed in its stages, such as when the Saxon word 'gut' gets replaced first by the Norman-French 'bowel', and then, when this is found too coarse, by the Latin 'intestine'" (1951: 94). Similarly, in polite company "piss" is replaced by "urinate" - and, much less frequently, by "micturate" (the word that James Strachey, the fastidious translator of Freud, prefers in the Standard Edition). Francis Grose says of the word "piss": "Good and current English till ca. 1760, when the word began to be avoided." According to Grose, "This avoidance led to an excessive imputation of grossness, hence of vulgar colloquialism" (1963: 263).

Green says that "piss" is perhaps "echoic" - that is, onomatopoeic. When the word "piss" is combined with other words - "about" or "around," "away," "off," "on," "out," "up," or "through" - the resultant phrases have different meanings. Green says that to "piss about" or "piss around" means to "waste time" or to "act in a pointless manner"; to "piss away" means "to waste"; to be "pissed off" means to be "furious, very annoyed"; to "piss on" means to "treat contemptuously"; to be "pissed out" means to be "exhausted" or "finished"; to be "pissed up" means to be "very drunk"; to "piss through" means to "do something with no difficulty" (1999: 921-2). Another relevant idiom is "piss-mean." Richard A. Spears says that a piss-mean person is "extremely angry and violent" (1981: 302).

Harold Wentworth and Stuart Berg Flexner define "piss off" as a phrase that means: "Angry; enraged; disgusted; completely and thoroughly exhausted; fed up; unhappy; forlorn." They say that "piss off" was "very widely used by Armed Forces in W.W.II and carried into civilian life afterward." They note that now the phrase "has passed into sophisticated use among the culturally elite or pseudo-elite" (1975: 393). In comparison with "piss off," Wentworth and Flexner define "piss on" as a phrase that means: "To act disrespectfully toward; to do anything to injure or denigrate another." They say that "piss on" is a phrase "often used to indicate an intention to ignore another's advice, feelings, etc.; an expression of anger at, disgust with, or rejection of a person or thing" (1975: 393).

My patient held his anger in rather than let it out. He repressed it. In this respect, to retain his urine was to restrain his anger - or control it. That is, my patient took the verbal expression "not to piss anyone off" literally, and he hysterically converted the metaphor into a somatic expression. Although he was pissed off, not only would he not piss on anyone, but also he simply would not piss. If he did not piss, he would not piss anyone off.

This is an example of what Freud calls "retention hysteria" (1893-1895, SE 2: 162). In this respect, Wilhelm Stekel notes that "micturition may be obstructed by psychic factors." As an example, he cites the inhibition that some men experience beside other men at urinals: "It is a known fact, for instance, that many men are unable to urinate in the presence of other men (in men's toilets)." In that situation, the inhibition is normal, but under other circumstances it may be pathological in the extreme. "Such disuria," Stekel says, "may reach the proportions of a serious retention" (1959: 227).

The inability to urinate even when there is the need to do so may indicate a physical obstruction of the urethra. This is a condition that requires immediate attention. A physical obstruction of the urethra may severely and permanently damage the bladder and kidneys. A psychic obstruction of the urethra may be just as serious a condition as a physical obstruction. A hysterical symptom mimics an organic symptom, but this mimicry is no less "real" and no less consequential. The cause, psychic rather than physical, may be very different, but the effect may be exactly the same. Urine is toxic waste that needs to be ejected. When it is retained, it builds up and backs up and may damage the bladder and kidneys.

The result may be uremia, a severe toxic condition in which constituents normally eliminated in the urine are accumulated in the blood, usually in kidney disease. In this respect, Georg Groddeck mentions one of his patients with kidney disease in his sanatorium. Freud says that Groddeck "is never tired of insisting that what we call our ego behaves essentially passively in life, and that, as he expresses it, we are 'lived' by unknown and uncontrollable forces." The term that Groddeck employs for these forces is "id" (in English translation, "It"), which he apparently derives from Nietzsche, as Freud appropriates the term from Groddeck. Freud proposes, after Groddeck, to call that part of the psyche that "behaves as though it were Ucs., the 'id'" (1923, SE 19: 23). Groddeck says that he received the patient with uremia "in the last stages of the disease and undertook the case in order to observe and make easy his dying." The "It," he says, was what was "keeping back the urine." As Groddeck interprets the case, "the uremia signifies the deadly struggle between the repressive will and the repressed material forever trying to force its way up, the important urine-secretion complex, which originates in earliest childhood and lies in the deepest levels of the constitution" (1976: 342).

Groddeck is correct to say that the conflict, or "deadly struggle," was between the "repressive will" and the "repressed material" - or, as Freud would say, between the ego and the id, but he is incorrect, I believe, to say that what was keeping back the urine was the It, or the id. As I would interpret this case, what was keeping back the urine was the ego. Rather than express the urine, as the It, or the id, would do, the ego repressed the urine. The result of this repression was the "urine-secretion complex."

In a discussion of the traits of the anal-erotic character, Ernest Jones mentions what he calls "the 'retaining' and the 'ejecting' tendencies" (1948: 428n.) These two tendencies are two phases in a process. The first phase Jones calls "keeping back," and the second, "giving out" (1948: 456). The anal-erotic character may retain feces or eject them, keep them back or give them out. What Jones says about the anal-erotic character applies also to what I might call the "urethral-erotic character," which may retain urine or eject it, keep it back or give it out. Retention and ejection are control issues. Jones says that one trait that distinguishes the anal-erotic character (and, I would add, the urethral-erotic character) is "the desire for self-control." According to Jones, "There are people who are never satisfied with their capacity for self-control, and who ceaselessly experiment with themselves with the aim of increasing it." The effort to establish self-control may assume, Jones says, "either a physical or moral direction" (1948: 423).

In just this way, my patient tried to control himself both morally and physically. He adopted two alternative and, to a certain extent, contradictory defensive strategies and tactics. He was both a Quaker pacifist and a karate martial artist. As a result, he had what he called a "dichotomous personality." The dichotomy was between peace and war. My patient had been in cognitive-behavioral therapy, but that modality had not enabled him to control his anger. "Cognitive-behavioral therapy tries to be rational about anger," he said. "I couldn't control my anger with the rational exercises of cognitive-behavioral therapy." What he wondered was whether psychoanalysis - which I call an affective-attitudinal therapy - would enable him to control his anger.

My patient's grandparents and parents were Quakers, and so was he. As he experienced the Quakers, they were a loving, supporting community who tolerated diverse opinions. They were like a family. The Quakers were opposed to war and committed to peace. As Christians, they believed that one should love one's enemies - a belief that Freud, incidentally, says he considers "incomprehensible" (1930 [1929], SE 21: 110). "The Quakers," my patient said, "advise you to look the other person in the eye. By looking the other person in the eye, you're supposed to make contact with the Christ in that other person, no matter how bad the person is."

Karate was an outlet for my patient. "In karate," he said, "I can let out my anger. I can scream. I can kick the bag. I don't have to prove it on the street or in the subway." As Bruce A. Haines defines karate, it "is basically an art of unarmed self-defense" (1995: 19). Haines notes that "when attacked by an aggressor, the genuine karate practitioner responds with what amounts to reflex action" (1995: 113). The authentic practice of karate is not offensive, or aggressive, but defensive. It is a purely reflexive defense against aggression. "Before karate," my patient said, "I didn't look other people in the eye - I was shy. Now I'm more self-confident. Now I have more self-esteem. In karate, you look the other person in the eye in order to see where the other person will attack - then you can defend yourself."

As both a Quaker pacifist and a karate martial artist, my patient looked the other person in the eye in an effort to defend himself. "Looking" at another person has a neutral connotation. "Staring" at another person, however, has an aggressive connotation. In confrontations at work, my patient did not just look at his bosses. He stared at them. "Bosses don't look me in the eye when there's a confrontation," he said, "but I have a way of staring them down."

If I were to interpret this strategy and tactic of "staring down," I would amplify the image. Amplification is a Jungian technique of interpretation. It is a comparative method. When Jungians amplify an image, they compare it to the same or a similar image in other contexts in order to establish an archetypal parallel. In this case, the relevant context is the folklore of the "evil eye." For my patient to give his bosses a stare was, in effect, for him to give them the evil eye.

Clarence Maloney defines the evil eye as "the belief that someone can project harm by looking" (1976: v). From a psychoanalytic perspective, the evil eye is a variety of projection - or projective identification. When one person projects the evil eye onto (or into) another person, the other person has to identify with it in order for the evil eye to have an effect. Belief in the evil eye is a superstition with an extensive, if not universal, distribution across cultures. "Why the evil eye" - rather than some other ostensibly evil organ - "should be so widespread a phenomenon," Brian Spooner says, "is probably a psychological rather than a sociological question." In this respect, Spooner notes that "staring is an act with connotations that vary from inauspiciousness to downright rudeness, according to culture" (1976: 79).

Belief in the evil eye, John M. Roberts says, is basically a belief that a certain look "of some, if not all, human beings can produce damage" (1976: 225). "This belief may rest, in part," he says, "on the presence of the steady stare as a signal of hostility and impending aggression in the human and even the primate ethogram" (1976: 225-6). What Roberts means by the "ethogram" is identical with what Jungians mean by the "collective unconscious." According to Roberts, "It is not difficult to see that a linkage between the hostile look and imputed hostility in others could be panhuman" - that is, universally human. If so, he says, belief in the evil eye is "potentially comprehensible to any human," although it may be actually articulate as a belief in only some cultures. "These latter cultures," Roberts says, "have made a special use of an action pattern that is available in the human ethogram" (1976: 226). What Roberts means by an "action pattern" is identical with what Jungians mean by an "archetype." From a Jungian perspective, the evil eye (steady stare) is an archetype (action pattern) available in the collective unconscious (human ethogram).

Similarly, Richard G. Coss, who mentions the frequent use of the steady stare "to intimidate others" in "social hierarchies, such as work environments" (1992: 185), speculates that the "human sensitivity" to the steady stare is a combination of "innate components" (archetypal components) from human evolution and "experience with aggressive social encounters" (1992: 186). In just this way, my patient used the steady stare in the hierarchy of his work environment in an attempt to intimidate his bosses.

In the case of Frau Caecilie, Freud says that when he interpreted her facial neuralgia in the context of the traumatic scene in which she experienced the remark by her husband as "a slap in the face" and then hysterically converted that verbal expression into a somatic expression, her symptom instantaneously vanished. This technique is interpreting by what James Hillman calls "deliteralizing" (1975: 136). The method is to reconvert the somatic expression into a verbal expression, a figure of speech, a metaphor.

I argue that psychoanalysis needs "a theory of metaphors in therapy" (Adams 1997: 29). I say that "what interests me is how metaphors structure the quite specific psychic realities of particular patients" (Adams 1997: 33). Rather than say, as George Lakoff and Mark Johnson do, that there are "metaphors we live by" (1980), I say that "to the extent that we remain unconscious, we are lived by metaphors" (Adams 1997: 38). This was the situation with my patient, who took - that is, mistook - a metaphor literally and was lived by it.

My patient localized his anger in two very different organs - his penis (or, more specifically, his urethra) and his eye. Rather than express his anger in an active-aggressive way, my client repressed it - that is, obstructed his penis, or urethra, and retained his urine. He expressed his anger in a passive-aggressive way.

I wish that I could report that when I interpreted my patient's urinary retention as an inability to pee because he was so "pissed off," or that when I interpreted his stare as a variety of the "evil eye," his symptom immediately disappeared. In this case, however, there was no cure as a quick fix by deliteralizing, or "remetaphorizing," his symptom.

My patient - the man who was so pissed off he couldn't pee - was certainly very different from the young woman I overheard behind me on the sidewalk as I was walking home from my analytic office one evening. She said to a friend: "It takes a lot to piss me off. I'm normally just 'whatever.'"


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