A recurrent dream of castration

A man in his mid thirties, who suffers from paranoid illness, is single, still lives with his mother, her only child, reported that for the last two weeks he is troubled with a dream that won't leave him alone.

I feel there is a baby on my back, like a backpack. I feel responsible for it and have to worry about its safety. I want to do things but cannot because of the burden.  My dreams which use to be full of adventures now are cut short because I have to worry about the baby coming to harm. 
When I wake out of the dream I find my head hard pressed against the pillow. 
 
Initially the only association the patient could come up with was that the backpack reminds him of going to school.  But that association led to no where. And soon we drifted into his usual paranoid complaints about neighbors keeping a watch on him and how he cannot get away with any transgression no matter how minute.
"Every time I have sex with a woman I get in to trouble. It is not like I am having sex with married women. But neighbors look at me as if I am trying to have sex with their wives. If I just wear a different style of cloth they start wondering if I am up to something. Recently I was hired by a lady to drive with her to New York to help her load some mattresses for her business, and while I was eating at the White Castle she was watching me as if I was wolfing down my food.  If I exercise in my backyard my neighbors come to their windows and stare at me. Even my mother doubts my abilities. She tells me that I am a dreamer. But so was Martin Luther King. My mother accuses me of doing nothing that has any practical value and for earning no money. But hardly out of school I became a connoisseur of classic cars and flipped a couple at a profit. I have a collection of old comic books which one day will fetch me a neat sum."

By expressing to me all these persecutory thoughts and feelings, which his mind is constantly conjuring and no doubt to keep a lid (inhibition) upon his taking chances with the world - even his ability to free associate -  undid the repression partially, and the patient now could come up with the following association, "I read, or perhaps saw on TV, that if you see a child in a dream it is yourself."

This immediately solved the riddle of who the child represented. And I asked him, "Behind the facade of protecting the child is it yourself that you are protecting?"

"That makes sense. But why I am protecting myself through creating a double of me as that child instead of protecting myself directly?"

"Because when the fear of harm coming to oneself is overbearing, the mind plays a trick to lessen its impact. It starts worrying about somebody else who if harmed will cause one even greater pain. This way one's fear for one's safety is lessened. The focus shifts to somebody else getting harmed instead of oneself. This reduces the autonomic and other physiological responses that are triggered if one is anticipating danger. For the harm coming to somebody else, even if to somebody very close to oneself like one's child, still does not pose as much terror as harm happening to oneself. Or at least does not mobilize body's physiological responses to the same degree. The body does not have to activate the cascade of stress factors to protect oneself, because the injury is going to happen to somebody else. It is a very important defense: shifting worry from one's own person to worry for one's child's, or a spouse, or a favorite nephew or the federal deficit or the future of mankind or the disappearing rain forests, or the global warming.

"Since in real life you do not have a child, in fact you do not have anybody close to you who you really care for, you are working out your fear of some harm happening to you by creating an imaginary child who you must protect. And since you deny your fears in daytime, and in fact do not feel much emotions when you feel threatened by your neighbors, for that matter the world in general, for you experience the world as a hostile place, these fears emerge in the night when you are sleeping and you try to work them out of your system in your dreams.

"But why did this dream start just two weeks ago?"

"Because for the last two weeks I am struggling with a bad crook in my neck?" the patient replied

"Crook in your neck? What in the world is that?"

"I don't know what you call it. But us black people call it crook in the neck when we sleep badly and wake up with our neck stiff and hurting. Generally it clears up in a day or two. But this one has been a bugger and has persisted for two weeks."

This explained the immediate cause of the dream. The pain in the neck was disturbing the sleep and the patient who is always anticipating grave harm because of his paranoia had raised its significance to that of a mortal danger. This was consistent with how he experiences the world: a dangerous place. The need to do something about "this impending catastrophe - the crook in the neck" would have woken him out of sleep. But to protect the sleep - for him to continue sleeping - the brain mechanisms responsible for dreaming generated the dream. And the dream, by showing that the mortal danger was not coming to him but to his dream child, lessened the overbearing emotion of fear which otherwise would have woken him out of sleep.

"Why is your head getting buried into the pillow?"

Patient countered it by stating that the dream was in color. Now we know that if the dream is  vivid, feels very real, is in color, it symbolizes intensity and it is reflection of the intensity of the wishes/desires that are invoking the dream. Many scenarios of wish fulfillment have been condensed in to one. Not unlike how in some movies the director starts in black and white to portray the emptiness of the lives of the characters, and then, as circumstances change, and the characters meet new people and new sources of pleasure, their lives become multidimensional and full of happenings and the director shifts gears and ratchets it up from black and white to color.

The patient then gave some more associations which hinted that his burying his head in the pillow was trying to retreat from these intense wishes. For intense wishes are often accompanied with heightening of danger. Striving for things invites competition, threats and actual aggression upon one's person. In digging himself into the pillow he was actually retreating from the dangerous world and seeking to hide in its crevices - it was a variation of the fantasy to return to the womb. It was this intense fear too that was perhaps causing him to keep his muscles defensively tight while sleeping, causing "the crook" of his neck.

The correctness of this view was further confirmed when patient said that his dreams are full of adventures, or rather a wish to embark on adventures, which are cut short because "I cannot be involved with dangers and cannot accept daring challenges because I have this burden, this responsibility for the baby."

When asked to give specific examples of adventures which are cut short by the fear of harm coming to the child the patient said, "Like climbing up a mountain or some other steep structure. Or to get out of a tense situation, like being in a small space with so many people around me."

Now we know that climbing symbolizes sexual intercourse. In fact in Hindi the vulgar term for sexual intercourse is a man climbing on a woman akin to mounting in English. Being in a tight spot with so many other people around perhaps symbolized competition with siblings and father over exclusive possession of mother's genital passage. And considering that a little child often symbolizes penis I made the following construction.

"Is it possible that the adventures are symbolic of sexual adventures and the danger is of castration, with the little child being your penis which will come to harm because of it?"

Little child symbolizing penis is a well known psychoanalytic fact - people often refer to their genitals as their little one -  and this kind of conjecture could be made with this particular patient for he has been seeing me for many years and is quite familiar with the concepts of Oedipus Complex, castration, and dream symbols.

To my great surprise patient said, "It is interesting you say that because the child who I am saving always is naked, he has an erect penis, despite his being a baby, and I may as well add that it is over my left shoulder that I look at the child."

This association strengthened  the view that the dream was an attempt on part of the patient to avert castration for forbidden sexual wishes.

I asked the patient why the child had erect penis and he recalled:
"When I was 11 I developed torsion of the testicles. My mother took me to the Children's Hospital. But they did not treat me right away, and sent us home and told us to come another time for there were so many children who had to be treated before me. And my problem could wait. But then a few days later the problem suddenly worsened. I was rushed to the hospital and they did the surgery right away. The White doctor who operated upon me said that the condition had gone so bad that he was about to cut them [testicles] off. He added that the left one looked worse than the right. The White doctor had a serious look on his face as if he really meant what he said. I did not want to lose my manhood. For I knew one could not have kids without the testicles. After that I had dreams of that white doctor cutting of my testicles for quite some time. I also thought that they would have operated upon me when I first went there if I was a white kid. And for them to operate upon me so quickly when we went the second time, I must have bumped off some white kid who was scheduled for surgery that day."

The patient at this point added another element of the dream.

"The child on my back is white. I was pretty white when I was born. Just like my grandmother."

So the patient's genetically determined excessive castration fear was further worsened by this unfortunate episode when the possibility of castration in hands of a White man almost became a reality. And to defend against it he had taken refuge in the belief that he was not black but white just like his grandmother. If he could turn white then the likelihood of getting castrated would disappear. And so in the dream he was defending himself from the fear of castration by making a double of himself as a white child. And a child who was not just white but who had an erect penis all the time - denial of castration through impudent defiance.

In his next session, a month later, he brought the following dream.

 I am a few streets away from my house playing basketball with my friends, two brothers, who I grew up with and who were nice to me and treated me with respect. Then another kid, a  neighbor of theirs, and I start fighting with each other. It is a martial art fight. The kid's uncle comes out who is blind. He has a white cane with red tip. We stop fighting and apologize to him for fighting like that and I explain to him that I live on Anna street. Then I return home and find that the boy with whom I was fighting had done a break-in and entry in to my mother's house. I call the police and grab hold of the boy. I see the boy wrapped around my hand as a backpack. I feel as if the burden of the boy who was always on my back as a back pack has disappeared for he is now wrapped around my hand.

We will not go in to analysis of the whole dream but only the parts that deal with the baby on the back.

The patient spontaneously associated that the boy who he is fighting with his own self. It is the part of him which he wants to [reject, project out, and] fight with. It is that part of him which if one follows the dream has failed to resolve the Oedipal conflict and is still seeking to find libidinal satisfaction through his mother - the boy with whom I was fighting had done a break in and entry in to my mother's house -and which was at the root of his illness.

Patient claimed that once he had this dream the  recurrent baby-on-the-back stopped. The patient and I agreed that the baby now instead of being a monkey on his back had shifted to getting wrapped around his wrist. So instead of the fear of castration completely controlling his life- sitting like a monkey on his back - it was now wrapped around his hand and thus under greater control.   

The humbug of Induction phase in Suboxone (Buprenorphine) Therapy

A shameful chapter of American medicine is the way the doctors authorized to prescribe Suboxone (buprenorphine)  have abused this privilege to financially exploit narcotic addicts. The latter are no match for the doctors. Not only because the balance is so much in favor of the doctor with the prescription pad in his hands, which the addict knows has the power to immediately end  withdrawal symptoms, but years of drug seeking life style leaves them emotionally and cognitively scarred, and they often feel like a thief, unworthy of asking anything of anybody. Finally when you are feeling physically sick from withdrawal you are incapable of negotiating with the doctor on his fees. 
Addicts are one group of patients whom the doctors should not charge more than what they charge their other patients for equivalent amounts of time.
It therefore comes as a surprise that while for their regular patients - who actually may require more medical skill, time, attention, and coordination with other medical personnel - doctors charge anywhere from 35 to 120 dollars, with Suboxone patients they want to charge 400 dollars for the first visit, and anywhere from 100 to 200 dollars for subsequent visits.
At least these were the rates when Suboxone first came to the market. The rates have gone down some since DEA now allows 100 instead of 30 Suboxone patients in one's practice, but, still,  most Suboxone-doctors nevertheless want at least 200 dollars for the first visit, and anywhere from 65 to 150 for return visits.
Also it is not uncommon for Suboxone-doctors to ask for additional monies besides what the insurance pays, which really is illegal.
Why they do it? And what has enabled them to indulge in this kind of highway robbery?
To prescribe Suboxone,  DEA requires special training - it can hardly be called special for it requires all of 8 hours of listening to lectures on a single day - and submission of the proof of having done so. DEA then issues a special unique identification number and voila the Suboxone doctor is born. Does that much of effort deserves charging 400 dollars to the patient and then hundreds more on subsequent visits?
Anyway, without this identification number, which is really the doctor's DEA number with letter X in front of it, the pharmacy does not honor the doctor's order for Suboxone.
It is this number which since only few doctors go through the special training empowers them to charge exorbitantly.
How difficult is that special training?
The training requires eight hours of passive listening to lectures in a one-day conference, delivered usually by two Suboxone specialists, majority of whom I have found to be just the kind who will gouge 400 dollars from some down-and-out kid who does not have a dime to his name, having blown all his money on drugs, and whose medical fees in all likelihood is being paid by a struggling spouse or a beleaguered parent.
Why more doctors don't take this training?
Because doctors like the rest of us are neophobic. If their practice is going good they don't want to get out of their comfort zone and acquire a new skill. But more so because of the prejudice we harbor towards drug addicts as trouble makers. And this contempt and fear of narcotic addicts has some merit. Addicts can be very difficult population to deal with when they are not as much interested in giving up their addiction but in procuring Suboxone to actually support their habit through selling it on the street and using the money to buy their drug of choice.
Yet charging these sick people - yes, some of whom who do indulge in crime, including prostitution, to support their habit, are often liars par excellence and on rare occasions can be hostile and outright assaultive to the doctor when he refuses to give them as much medications as they would like - such high medical fees is unethical.
Why did the DEA place this special training hurdle?
The need for special training to prescribe Suboxone arose because the way Methadone Clinics had degenerated into turning narcotic dependency - from the mildest to the severest - into a life long affair of going to those Clinics.  Anybody who came to them instead of being put on appropriate dose of Methadone which would have been equivalent to what they were abusing were actually put on way higher doses of Methadone than were necessary to prevent withdrawal and then instead of tapering down, believe it or not, the dosages were  ratcheted upwards to make their habit worse. This was the standard modus operandi of these Methadone Clinics and its logic was to make whoever came to the Clinic its permanent client. It may not be too out of the way to add here that many of the Pain Management Clinics also are nothing more than fronts to hook people on narcotics, spinal steroid shots, and other medical shenanigans for life.
So it was to prevent Suboxone treatment turning into another Methadone Clinic fiasco that the DEA, with good intentions, made it compulsory for doctors to get that 8-hour special training before they could prescribe Suboxone, and to restrict the doctor from not having more than 30 Suboxone patient at a time in his practice. The latter of course was placed there for the doctor to not give up his medical practice and become a Suboxone pill mill.
Alas DEA did not succeed! It may not be wrong to mention here that quite a few of these specially trained doctors are doing with Suboxone what the Methadone Clinic entrepreneurs did and still do. They often start patients on three Suboxone a day, 90 tablets at a time, and tell them that they should be at such a high dose for a whole year, before they will be ready for tapering, and thus hook them on Suboxone, which by the way is as addicting as any other opiate.
And finally, after this long introduction we come to the issue of the need for special induction phase in initiating Suboxone treatment.
Much of the mystique of prescribing Suboxone lies in its complex induction phase. Many doctors even after getting that special training and identification number will not take the first step of seeing opiate addicts because they find the induction phase of treatment too complex, confusing and impractical. They are too scared that they will mess up the treatment of the patient by not following the induction phase protocol and thus get in to trouble. And this reasoning is not entirely baseless. Not the fear that they will somehow harm the patient but that they will not be able to adhere to the protocol.
If one reads the drug company's information package insert, one is not supposed to just prescribe Suboxone and tell the patient to not take the first dose of it till the withdrawal symptoms become unbearable, but to have the patient come and sit in your office till you decide that  his withdrawal symptoms have become unbearable and then personally give him the first dose.
And there are further hurdles. The first dose is supposed to be not that of Suboxone - which is a combination of Buprenorphine and Naloxone - but of Subutex - which is Buprenorphine without Naloxone. The rationale is that Naloxone which is an opiate antagonist will worsen the opiate withdrawal. This is a bunch of nonsense. If you instruct the patient to not take the first dose of Suboxone till the withdrawal symptoms become unbearable the Naloxone in the Suboxone hardly has a worsening effect upon the withdrawal.
The guidelines also want the doctor to write the first prescription for just two or three Sabutex tablets and ask the patient to go and get them from the pharmacist. Then the doctor is supposed to assess him hourly or bihourly with a special rating scale called COWS - Clinical Opiate Withdrawal Scale - and only when the rating scale tells the doctor that the patient is in sufficient withdrawal the doctor is supposed to give him the first dose of Subutex. And then the patient is supposed to wait further for the doctor to keep doing the rating scale periodically and decide if he requires more than one Subutex tablet or not. And this assessment shenanigans is supposed to be carried on for the next few days.The guidelines require the patient to come multiple times in the first week for doctor to assess him daily with the rating scale to further fine tune what is the most appropriate dose of Subutex/Suboxone for him - one, two or three. And since it is illegal for the doctor to hold medication in the office that is prescribed for a specific patient, the latter is supposed to go every day to the pharmacist to get his daily supply of two or three Subutex.
 If one wants to avoid sending the patient to the drug store repeatedly, the guideline also gives the doctor the wonderful option to keep a supply of Subutex in the office. An option that given the penchant for American Justice to trap and turn one and all into the category of criminals to expand their business, can land the doctor, if he is not dotting every i and crossing every t in his bookkeeping, in serious trouble.
Does any doctor really follows these guidelines or more importantly is it really possible to follow all these commands in private practice? Are drug addicts capable of complying with this kind of quackery? Do they have the money, resources, gas in their car, if they have a car to begin with, to go daily to the pharmacy and get a fresh round of Subutex? Does their insurance - most of them have Medicaid or are uninsured - covers these Subutex prescriptions? Is it really practical for withdrawing opiate addicts to sit in your waiting room with your regular patients for hours at a stretch without scaring them? Does the mumbo-jumbo of COWS, for that matter any rating scale, really superior to clinical assessment of the patient through observation and common sense questioning by the doctor? Is any drug addict really capable of  coming to your office, get the prescription of Sabutex, take it to the pharmacy, wait there for it to be filled, return to your office, sit there for hours for assessments and then go home, only to repeat the routine the next day? And finally after giving the first dose of Sabutex and making the patient sit in your waiting room and periodically assessing him really tells you much whether the patient requires one, two, or three Suboxone a day?
The answer to all the above questions is a resounding no.
No doctor really follows these guidelines? They do some half-ass going through the motions of them, enough to convince themselves that their charging 400 dollars for the first visit is justified.
Yet these top-down guidelines exist, and turn away many doctors from treating narcotic addiction which has become such a large problem across the nation.
I have been prescribing Suboxone for eight years and must have treated hundreds of narcotic addicts with good results and without practicing any of these complicated rules of Induction Phase of therapy.
All I do is to make a careful clinical assessment of how much opiate the patient was abusing, how severe is his withdrawal, how honest and sincere he is in giving up his habit, and if he is not there to get some Suboxone as a temporary fix because he has run out of money and wants to stave off the withdrawal till he can go back to his drug of choice.
The first visit lasts for 45 minutes if he pays me 110 dollars, or for 30 minutes if he can afford no more than 70 dollars. And through this assessment, which is not corrupted with stupid rating scales - which are made for subnormal doctors who cannot think of medicine in qualitative terms but must turn everything into numbers - I can almost always make out whether the patient requires one, one and one-and-a-half, or two 8-mg. Suboxone tablets a day. Almost 90 percent of the patients fall in to these three categories. Very rare ones require three tablets a day. Patients who are switching from Methadone to Suboxone almost always require three tablets - incidentally of Subutex instead of Suboxone - because they have a very bumpy withdrawal.
I give the patients 7 or 11 or 14, and for very few 21 tablets, for the first week and ask them to come back when that period elapses. I emphasize to them to not take their first dose of Suboxone till their withdrawal becomes unbearable. Most of the patients are not Suboxone naïve, having already taken  Suboxone here and there, obtained from friends or bought on the street, and they know very well how not to take it till the withdrawal symptoms are intense. Their knowledge of their withdrawal symptoms is first hand and much superior to any assessment done by the doctor directly or through his rating scale.
In a week when they return, I reassess their Suboxone need and titrate the dosage up or down. It is rarely that I have to titrate upwards. In my practice there is always a constant pressure to keep ratcheting down the Suboxone, for it is as addicting as any other opiate.
I have never had any failure with this simple approach. It is also not a huge deal if some patient was given 14 tablets for first week when 11 or 7 would have sufficed. Also it is a rare patient who has gotten 7 tablets when 11 or 14 would have been more appropriate. And such a patient always has the option to come a couple of days earlier if he runs out of his Suboxone before the 7 days.
Why if initiation of treatment with Suboxone is so simple have the DEA, the doctors, and other interested parties have made it into such a rocket science?
Because there is always a tendency in humans to make their profession look more complicated - which justifies them charging more money and makes them feel more important than they are - than it is. Also it increases the scope of employment. There is a huge industry to treat narcotic addiction. The government regulators if they can make medical business more complicated and time consuming then their power increases and their department size increases.
Finally this kind of bullshit masquerading as evidence-based science is a significant component of  medicine. The art or science or quackery of medicine is heavily laced with many such useless protocols and  unnecessary regulations. The reason for this is because the payment for much of medical activity is made by third parties. So there is a built in mechanism to make medical treatment as dilatory and nonsensical as one can get away with. When one analyzes these protocols carefully most of the steps present there are useless, if not outright counterproductive, often harming than helping patients.
I remember in 1976, when I started my residency in psychiatry to admit a mental patient through ER would take all of 30 minutes. There was no money in keeping them in the ER. Now on average it takes 17 hours. For everybody and his mother, aunt, and brother are having a go at the patient in the ER in the name of triage and multi-disciplinary approach.  Are these multiple assessments by the clerk, nurse, social worker, ER doctor in the ER have any real meaning in improving patient's psychiatric condition. All they achieve is to exhaust the patient, and his relatives who have to sit through this period of ordeal in the waiting area, without doing any good to him.  But all this has become necessary to generate a stackful of medical notes so they can bill thousands of dollars to the government and private insurances and have documentation to prove it.

Snake dreams and the phallic competition with the father

A highly gifted artist who draws cartoons as good as any Disney animator but never made commercial  use of his talents because of a fear of failure and has spent his life - he is now in his mid fifties - in a low clerical position because of the job security it offered brought to therapy the following recurrent dream that he claimed has periodically occurred to him all through his life.

Before telling the dream he added that it makes no sense for him to repeatedly dream of an animal that he detests and dreads when he is awake.

There are two snakes one of which is a diamond headed rattle snake the other one is black.

When asked if in all his dreams there are two snakes he said no: sometimes two, sometimes one, sometimes many. The latest dream had two snakes.

Now a long time back I had read in Karl Abraham's writings that snake in the dreams  often symbolize "phallic competition with the father". I had also once analyzed an Indian man's dream of being chased by a five-headed cobra (shesh naag) which on analysis had shown to be a dread of castration in hands of the father - for daring to compete with him and wish for his death - and the five headedness of the cobra was denial of castration - multiplication of the threatened object, so if one is lost there still will be some in reserve.

So my interest in the dream was piqued to see if this one too will prove to be some form of competition with the father.

"Why it is a diamond headed snake?"

"It may have to do with the triangular shape of the snake's head. Also the scales on its body were full of triangles."

Whether the triangles stood for female genitals could not be confirmed. This avenue was explored because of the theoretical consideration that coming across the female genitals during the Oedipal period in the little boy produces the horror of castration for he immediately concludes that it must be the result of punishment meted out for playing with the genitals (masturbating).

"Why is the other snake black?"

"There was actually a black snake that I once saw crossing across our house. I think it is taken from there."

"Is the diamond headed snake your mother and the black snake your father?"

The patient said it could be but gave no further associations that could confirm or reject the construction.

The patient then stated that recently his paranoid illness has taken an upswing. He feels unmarked black cars, with federal agents inside them, are following him whenever he is on the road. 

Now this patient has had bouts of paranoid breakdowns since the age of 34. These paranoid episodes
always begin with unmarked black cars following him. They quickly escalate into auditory hallucinations in which he is berated for being a pervert who indulges in all kinds of bad sexual practices including child molestation. These accusations have little to do with his manifest sexual behavior for his whole sexual expression is limited to masturbation and even this he does not indulge in more than twice a month. A limit which when exceeded results in paranoid constructions where he is constantly watched by federal agents, security guards, spy cameras, and condemnatory voices, all of which occur, along with a rise in the affect of guilt, to prevent him from indulging in masturbation and the associated [incestuous] fantasies.

His first episode of auditory hallucination began when he was dating a girl at the age of 34. He had only dated once before, a decade earlier, which had ended unsuccessfully because he would repeatedly tell the girl that wouldn't she be better off with somebody else. With this second woman the relationship had almost come to the point of getting engaged but then while having lunch with her in a restaurant in company of his brother with whom he is inseparable he had heard the man on the next table say that he (the patient) was fake and incompetent and should tell the girl he was hoping to marry to go and find somebody better than him. Later that evening the three had gone to the movie and the girl had abruptly left the two of them in the theater and had called off the relationship no doubt sensing his pathological sense of inferiority. Patient had concluded that she had walked out of his life to find somebody who had more money than him. Interestingly he is a millionaire despite his humble job because of a shrewd investment in stock market that he had made in the Eighties. The money though does not have any influence upon his daily living where he is frugal and wears very modest raggedly old clothes.

Few months after the breakup, he had a major paranoid breakdown.

The patient recalled in the session that fateful lunch, that first instance of auditory hallucination, the subsequent full blown paranoid schizophrenia, and then returning to the present told me as to how a woman who works with him, and who was acting quite interested in him had asked for a sum of money and on obtaining had become indifferent again.

"Was the dream sparked by this latest rejection?"

"Yes. Since she gave me hope and then disappeared, a repetition of what has happened to me before, I have been having suspicions that my bedroom is bugged, that there are spy cameras throughout the house, that my television can read my intentions, and the security guards from the campus where I work are standing outside my windows."

This had to be interpreted as due to an escalation of his hostility towards the world because of the latest rejection. He was trying to discharge his anger towards women - his mother was very domineering and had always held him back from taking interest in girls -  through sadomasochistic masturbatory fantasies and which were being controlled out of respect for his parents, for the fantasies were primarily directed against them, through creating paranoid structures of being watched by spy cameras, security guards and black cars. 

Patient at this point recalled that the dreams of snakes almost always occur a day or two before going to the confession. He goes there once a month and mostly to get absolved from the guilt of indulging in masturbation.

Patient was then asked if there were any more details to the dream. All he could think of was that the snakes were under his bed and he was deathly afraid of them.

"What exactly were you afraid the snake would do?"

"They will bite me on my penis," the patient replied.

So the snakes symbolized the father who would castrate him. Though the castration was shown not at the phallic level of psychosexual organization. Instead the great fear had caused a massive regression  all the way to the oral phase, where instead of his penis getting cut off by a human father he was quivering with fear over getting bitten by the snakes (the father substitutes). 

Here one recalls how in Little Han's case the castration fear was being worked through by dreading getting bitten by horses and in Wolf Man's case the castration anxiety had shifted to the fear of getting eaten by wolves.










 

A dream of getting bitten by a snake twice

A woman in her mid-thirties, twice divorced from two abusive marriages, and who despite a great need for love now lives a lonely existence dreamt the following:

Someone is drawing blood from my arm. A black snake with yellow underbelly hanging down from the ceiling bites me on my finger twice. The bites were sharply painful.

Since the patient is very shy and laconic in her descriptions, I knew there was more to the dream than what she was reporting, and if enough encouragement was given would bring up more details and on being coaxed recalled that:

She was sitting in a chair like one does in a clinical lab. Her arm was raised instead of being placed on the hand board, which is peculiar because arm is not kept in that position for blood drawing. The woman who was drawing the blood had short brown hair coming down to the neck.

The dream had occurred 3 weeks ago and the day's residues that had sparked the dream were not readily available. But, eventually, when it was suggested that the woman who was drawing the blood was perhaps she herself - for she has short brown hair which come down to the neck - she countered with, "No those hair are my aunt's. She, my mom and my grandmother came to visit me three weeks ago and the same night I had the dream. My aunt has short brown hair like that."

When asked as to why her aunt is drawing blood, the patient began talking about her grandmother. She declared that the grandmother is quite like her. She too has agoraphobia and like her (the patient) rarely leaves the house. In fact the patient was surprised that she had mustered the courage to ride along with her two daughters and come to the patient's house. She wondered whether behind the façade of aunt it was not her grandmother who was drawing the blood. 

"Why would it be so?"

"Because I look up to my grandmother. She is a feisty one, full of energy and wisdom. So if the blood drawing is happening to cure me, it would be my grandmother who I would want to be my healer."

"And what it is that she is curing you of?"

"You know I work in a dog boarding place. A big Labrador injured me quite badly on my shin. It is painful and has not been healing. Surprising no blood oozed out of the wound when it happened. If it had perhaps the wound would have healed faster. So I must have made my grandmother, behind the figure of my aunt, draw the blood to heal me. "

"Was it your shin pain that was being experienced as the snake bite?"

"Must be. The pain was throbbing in quality and the snake bite occurred in quick succession twice."

"But why did the experience of pain from the shin shifted on to the finger, and as a snake bite?"

"Because my grandmother must complain about everything and find reasons to be paranoid wherever she is. The minute she entered my house she started looking at my backyard where there is overgrown vegetation and started worrying about there being a snake on those lush creepers. So it was my grandmother's bringing up her fear of snakes that sparked the dream."

"Why the snake is black?"

"There is actually a snake that lives in that foliage. Though I have not seen it this year. In fact the foliage at my backyard is so lush and wild because I have stopped going out in to my yard out of fear of running in to that snake. I hate snakes. They give me the creeps. Though they eat bugs and critters which is good. For I hate those creepy things too. The snake in my backyard is black and identical to the dream snake. It does not have yellow underbelly though."

"Why the yellow underbelly?"

"Yellow underbelly means it is a poisonous snake."

"Why would you want to be bitten by a poisonous snake?"

"To be cured of the other pain. My life is full of pain, fibromyalgia, fatigue; in short I never feel good. So I must me introducing one poison in to my system to get rid of another. Kind of homeopathy doctrine. That must me the reason too for my hand being in that awkward position. Instead of getting my poison drawn out by my grandmother through the needle and syringe, I am opting for a cure through getting bitten by snake."

"Why twice?"

"Because I was married twice. Both were snakes. They both were abusive, made my life hell and gave me agoraphobia. They were good riddance, but I still crave for love. So when the pain from the shin injury was about to wake me up I must have started dreaming of finding a cure for it by finding a man, a wish that must have been counteracted by the memory as to how the cure would tantamount to being bitten by a snake."

We still did not quite make out as to why the dream chose her aunt and the figure of her mother and grandmother behind it to draw the blood. This conjecture was not confirmed but the three women are  the only people she relates with and avoids all others. So when the dog injury was disturbing her sleep, the dream was generated in order to find a cure for the pain and the injury. First her mind harked to the familiar figures of the three relatives and a composite  of the three was drawing her blood. But then the libidinal wish, finding the three women as inadequate objects for what she really needed, began contemplating relationship with a man [that would take away the pain]. However the traumatic experiences with the two ex-husband nixed that outlet as well - the cure would have been worse than the malady."
 

An unconscious conspiracy by the pharmacists, physicians and drug companies to overmedicate patients

When a doctor writes a prescription for medications that should be taken only when the need arises he puts the abbreviation p.r.n. It is an acronym for Pro Re Nata which is Latin and therefore Greek for 99% of the doctors. Nevertheless it does not prevent them for using its Latin origin to make their profession look more mysterious and prescriptions unfathomable, justifying charging patients more than their labor warrants.
My problem with p.r.n. is not that it should not be ordered, and that many medicines should not be taken only when needed. For example instead of taking Tylenol routinely it is better to take it only when pain or fever arises. My problem is the way pharmacies label the p.r.n. orders.
If I write:
Xanax 1 mg. tid p.r.n. [t.i.d is another Latin obfuscation]
which means that 1 tablet of 1 mg Xanax can be taken up to three times a day but only if there is a need for it, the pharmacy will write on the label: take three a day as needed.  
Writing it this way gives the impression to the patient that he should take three tablets of Xanax a day as [it is] needed.
It is a very subtle way of encouraging patients to take more medications than they should. This is especially true with anti-anxiety agents and narcotic pills where there is a tendency to take more medications than prescribed to begin with. As needed is interpreted tendentiously that they should take the maximum allowable dose.
Wouldn't it be better if the instruction reads: take up to three a day if needed.
If needed is much better than as needed when labeling prn orders.
Perhaps the ideal way would be: take up to three a day but only if needed.

A Problem Solving Dream

A man in his late fifties, happily married, presented the following dream, which he had dreamt the night before the therapy session:

In the dream, my wife and I were in some kind of workplace together. We both worked at the same place and for the same manager. I suddenly found I was working on a phone modem. The modem was in the form of a metallic bag, kind of like potato chip bag made out of the foil, wrinkled and a silver/black color. As I sat at a desk trying to flatten this bag out, the person I understood to be our manager said, "I can't get through on this phone line." To which I commented "That's because I am working on the modem for that line. I'm just about done and you can use it in a moment. It will be faster because I've adjusted the settings."

The desks of my wife and I were close to one another in the first row of the office. Suddenly, the outside wall of the office where our desks sat and the ceiling were gone. An open, grassy field appeared next to our desks. Walking into the field right next to our desks was a musical band of about 10 Caucasian men and women.  They formed the shape of 'L' and started playing instruments which was loud. Some of he women in the band started dancing by lifting their legs to their right side but I noticed they were not in sync with each other. I thought at the time that it would be almost impossible to work with that much noise (from the band) in our office. My wife was on the phone at the time looking at the band and laughing about the circumstances.

The patient had written out the dream but when asked to narrate it anyway, made one addition. His wife and he were facing the East.

Associations to the elements of the dream were not readily available. As to why he was facing the East he could just say that he is generally aware of the directions as to which way is North or South while dreaming. This peculiar feature of his dreams had been subjected to analysis previously and it had to do with his great need to be moored to reality even while indulging in dreaming (fantasy life). His parents had got divorced when he was 10 and this had had a cataclysmic influence upon his psyche and for a while he had felt as he had no direction to his life.  He did not know which parent he should live with, whether to live or not live at all, and whether he will be able to face the future without the joint protection of his parents. He had emerged out of this great turmoil quite well but with a scar. He had a tendency to go into states of mild depersonalization. He would suddenly go in to brief periods in which he would feel as if he was there and yet not there. To counter these attacks of derealization in all his other affairs he had become hypercathected to reality and even in his dreams he could not abandon the necessity to know as to which way was North, South, East etc.

When asked where did the dancing band came from he said that next week he is going to Key West where there is a bar called Sloppy Joe, where Hemingway use to hang out. Every year they have a Hemingway-look-alike contest around this time. His wife and he are going to it. The patient does have quite a resemblance to Papa Hemingway - flowing white beard, generous body girth and a benevolent facial expression, and he is hoping to score big in the contest.

He expressed some misgivings about being there and not just because it is crazy to go to Key West in July - he hates the heat and humidity of Florida in summer - but because he and his wife are very religious and conservative and the bar represents for them dancing, singing, partying and other kinds of "debauchery".

When asked if the singing and dancing band in the dream were representing the fear of giving in to the   temptation the patient said, "I'll be damned if that is not what it means. For those people in Key West area are a lascivious lot while I and my wife are just the opposite, and I have mixed feelings about getting into that revelry."

Once established that the singing band had come into the dream to represent the much anticipated visit to  Key West which was to take place the next week, we had to find from where was the actual visual imagery  taken from. And here the patient told me that the night before he ordered on pay-per-view a movie called "After Shock" where a bunch of young Americans go to Chile and while living a licentious life are struck by an earthquake of the magnitude of 9.5  which causes a cataclysmic upheaval; disasters of every kind are unleashed with criminals escaping out of prison, looting and raping women.

So the singing band was imagery of crime and punishment. Indulging in sin and suffering its consequences.

On being asked if anything else happened on the day before the dream he recalled that all evening his wife was complaining about her problems at work. She is a nurse who works as a case manager in a hospital where she has to make a judgment call whether the patients admitted to the ICU meet the insurance company's criteria for inpatient care or not. It is a difficult and thankless job where there is constant confrontation with irate doctors and insurance company representatives. That particular day her immediate supervisor was not present in the hospital and she had to go to the manager of the entire department to resolve an impasse with a doctor. She had been unable to reach the manager on phone. 

The patient who is retired is the sounding board for his wife. All her frustrations at work she relates to him when she comes home, and he sits with her, and tries to find solutions for her and sometimes feels as if he works along with her. It was from here that the visual picture of their sitting together at the workplace was composed. We could not decipher as to why they were on the first row. It was perhaps related to the fact that before retirement he was head of security in a Multinational Corporation where he always felt cut above the rest and he was bringing that same attitude and skill in helping his wife.

So when his wife lamented to him about how difficult it was for her to reach her manager and how frustrated she felt about it, his mind at once began to work upon resolving the issue and the problem-solving continued into his sleep, emerging in the dream as trying to fix the modem.

As to why the modem was shaped like a potato chip bag with wrinkles the only association that came and which to some extent was suggested by me was that the women  with whom his wife works are all getting up in years and are kind of old bags with wrinkles. The manager who she tried to reach unsuccessfully is a younger woman who really does not know what she is doing and is not a nurse but a social worker, a political appointee, and who per his wife lacks proper training to have the correct feel for medical complexities of the ICU, even a correct understanding of medical terminologies. His wife therefore dislikes calling her. In the dream the patient was reversing the situation and displacing the frustration of his wife trying to reach the manager in to its opposite. It was now the manager trying to reach out on phone and unable to do so and the patient was in the position of power and only through his efforts could the manager use the phone line. So the dream though it had to do with his wife's frustrations at work was showing him as the central character. Dreams truly are totally egoistical.

As to why the modem was black and white the patient said that the case managers who are about 10 in number are distributed in two sections of the hospital. Some of them are in the new wing and have a better work venue while others are in cramped quarters and have to share desks and computers with doctors of the ICU and they are constantly being interrupted by the patients and their relatives. This was given a pictorial representation in the dream:  I thought at the time that it would be almost impossible to work with that much noise (from the band) in our office .

Per patient the silver/black of the modem was taken from the silver and black stethoscopes of the doctors which often lie around in the area which they share with the case managers.

He added that the case managers in the old section of the hospital dislike the lack of space and having to share the desks and computers with doctors with whom they are often at odds. I wondered to the patient if the lack of coordination between the case managers with the doctors was reflected in the out of sync dancing of the musical band.

The patient said that the whole situation there is out of sync. They have a difficult job with constant wrangling over who should stay, who should be discharged and who should be sent to the observation unit. She is often worked up over what happens in that hospital but sometimes we have a good laugh at what takes place there. In the dream this laughing at her co-workers was shown as laughing at the performing band.

"Why did the walls and the ceiling suddenly disappear and you were transported to the open grassy field?"

Patient claimed it was the wish to get out of her stifling work environment and be on vacation.

"Why were the dancing band 10 in number?"

 "It has to do with The Ten Commandments. Whenever I think of number 10 I think of the Ten Commandments. You know how religious I am. Whenever in doubt I think of how God would have handled the situation. We went to sleep talking about my wife's problems and then this worry was in back of my mind how to deal with those wild people in Florida. So I must have been thinking of God and The Ten Commandments as guidance to deal with the two situations."

I wondered if the L shape of the dancing band was not taken from the epithet 'lascivious' but I did not communicate this to the patient and it could not be confirmed. I asked him instead, "Why were you facing the East?"

"Whenever I think of the Holy Land I think of the East. So I am looking to the East as if God resides there,  like how the Muslims pray to Mecca."

"Why are all the band members Caucasian?"

"This has to do with Zimmerman case. Yesterday I was watching his trial. That must have activated the issue of black and white in my mind and and you know how I scapegoat Blacks when anything goes wrong politically. I blame Obama for everything that is wrong in the country. So when my wife was complaining about the manager and the work I must have been thinking that she is Black and therefore she was not to be found on the phone. But she is white and so are all other case managers and her supervisor. And that may  the reason why my dream is making my wife laugh at that unsynchronized dancing as if to say that you all may be Caucasian to the boot but still haven't got your act together."

The modern scientific research on sleep and dreams makes a big deal of how during sleep and especially during dreams we become smarter than we are normally. And this kind of praise of our abilities gets a lot of media coverage and we lionize the researchers who come up with some corny experiments to show those who sleep or dream show astonishing improvement in their memory and creativity. And they all quote the historical example of how the structure of benzene ring came to the mind of that great scientist in a dream. Hundreds of millions of dollars worth of research money goes into showing how wonderful our mind becomes when it is oblivious to the world and snoring. All this belief that in dreams we become super smart  is bunch of baloney. There is often intense problem solving activity shown in dreams and it is often  accompanied by strong emotions as if one is really trying to do some intensely important work. But careful examination shows that the problem solving was all a facade. Behind it was just some wish or another trying to get fulfillment. In this dream too, the dreamer was doing some intense problem solving - full of sound and fury - on a modem. But on closer examination that problem solving was being done on a potato chip bag with wrinkles. And it was all for enabling someone to make a phone call through repairing the blinking lights of a modem! Something which even a child will see through as problem solving worthy of three stooges. 

A dream confirming Zombies are our own evil impulses projected upon others

A high spirited woman, in her early thirties, mother of two, 12-year-old boy and  a 2-year-old girl, living with latter's father, whom she must incessantly criticize, because of a constant need to not feel inferior to men, brought in the following dream:

[Though even before telling the dream she broke into laughter as to how silly it was and declared, embarrassingly, that the dream could not possibly mean anything. In fact she wanted reassurance that every dream - and every single detail of a dream, I interpolated - has a meaning and there will be some normal thoughts behind her dream before she would proceed further.]

I am in a car with my friends - not my family members now - going to a mall. I am passenger [not driver]. Though they are my friends, only one of them I know, or at least can remember well enough now. She has been my best friend since childhood. Though recently we had a falling out.
In the mall - it is a big mall - we find out that it has been taken over by zombies. [The girl could not restrain herself from laughing at this point.] They are not mindless zombie who don't know what they are doing but intelligent zombies. They bite my friends who turn into zombies as well. It is not a violent bite. Not like how zombies devour and tear you in to pieces. But a gentle bite. Finally seeing everybody turning into zombie I let my friend bite my hand and I turn in to a zombie too. [she laughed again at such a girlie conclusion of the dream and added that I am surprised I agreed to it so readily. For my nature is to kick ass and not give into anything so easily].

The girl's correction that she was not with her family members but her friends gave the clue that the friends were 'replacing' the family in the dream for the purpose of repression. When two thoughts like that follow each other then one can immediately assume an internal connection between the two and in her case the disclaimer confirmed that the process of repression was trying to make it doubly sure that she tell us that the two thoughts have nothing to do with each other. In reality she was using her friends as a substitute to work out her conflicts with her family [through the medium of dream].

This construction was immediately rejected by the patient, but only to tell me in the next breath that the  friend whose identity she can still recall is as good as family, almost a sister. They grew up together and she is like an alterego. "Her father and my father were alcoholics and both died young. She is 4 days older than me. We did drugs together as teenagers. We always got into trouble and together. But there were differences. While, her parents would ground her for a month for each transgression my parents within hours would forget what punishment they had given me, and I would be free to do whatever I wanted to by the next day.

"One would have thought she would have turned better than me with all the discipline she got. But it happened just the reverse. Though both of us did drugs, and no doubt to escape from the horrible conditions that existed in the house, especially the death of our fathers, she went downhill far more than me, and became far more boy-crazy than me. In fact she had no self esteem and would sleep with anyone who praised her slightly. She lost her kids to protective services because she was so far gone into drugs. I think the discipline did not work because her parents did not practice what they preached. My father was alcoholic too, but he did not hold me to higher standards than what he could practice. Her parents were druggies as well, but punished her severely for doing the same thing they were doing. It made her a chameleon. While I take punishment on the chin. She escapes them. As long as she can lie her way out of it she will do drugs and other creepy things. Not me."

"Why are you two going to the Mall?"

"We both are adventurous; Libra. We liked doing things spontaneously. However, there is a difference. I like to go against the grain, but she is a girlie sort. She likes to gossip. I think we are going to the Mall for different purposes. She is going there for buying soft stuff. Catty stuff. To make herself look vulnerable. I am going there to meet someone to kick his ass."

I have always found that Malls in dreams symbolize meeting place. Like a fair where one will meet someone for adventure, romance and life partnership. Agoraphobia arises from the same complex. A dread of coming out a loser in such an encounter provokes anxiety attack. One ceases to go to marketplace/mall out of fear that on not getting what one wants one may lose control and do something drastic.

"Where are the zombies taken from?"

"I don't know; they come all the time in my dreams. But usually they are mindless and aggressive, killing and devouring people, and I am afraid of them. But this time I find them half way decent, feel a little sorry for them, and they are even not mindless."

Recent work in therapy sessions had softened her attitude towards her boyfriend who she always criticized as mindless. So the criticism of Zombie was criticism of men. "They are dickheads and mindless, as good as zombies," was her frequent attitude towards men. Underneath, of course was her fear of them. Her father's aggressive and alcoholic ways had made her fearful of men. But she had also strongly identified with his aggression and had rejected her femininity. She took great pride in being adventurous. She had declared in other context her dislike for knitting, gossiping, wearing high heels, buying frilly things, and eating chocolate and hanging around in shopping plaza for hours."

"Why are they biting your friends and turning them into zombies?"

The girl insisted that the zombies were girls and boys. By getting bitten they were becoming ordinary people who go along with the program. "I on the other hand will never go with the flow. I refuse to be like all these girls, who will suck up to men."

"Why are you putting your hand out to be bitten then?"

"I guess, I am tired of sticking up for my rights and denying my feminine side. Remember the dream where I go to the Mall and shop around and buy high heel shoes with my mother and you interpreted that deep down I have a very strong feminine side which wants to find expression. It perhaps is making its comeback again in this dream. For now I remember the last part of the dream, which just came back to me.

We come out of the Mall and I don't know where I should sit. Like I lose my perspective. Everything looks different.

I guess it means I am ready to look at the world from a woman's point of view, even if I feel I am lost and cannot find my bearings. I went to the Mall as a passenger in the car. I think I am ready to let other women, chiefly this friend of mine, who acts so girlie, to show me how to be more like a woman."

There was element of the dream that had not yet been explained. Why were the zombies quick and full of vitality instead of moving stiffly, mindlessly tottering and barely able to stand up straight as would happen in her previous dreams?

The patient and I could only come up with the following explanation:

During the period when she was very competitive and hateful towards men she was full of evil impulses towards them. These impulses emerged as constant criticism of males during the day but in  night, in sleep and dreams, they were shorn of their verbiage and appeared as pure visual images. The visual images and behavior of zombies gave the best  representation to these evil impulses.  What she wanted to do to those mindless/dickhead men now appeared through the defense mechanism of projection as zombies attacking and devouring her.

As to why the dreams did not show evil men attacking her directly we could only conclude that in dreams while the brain is not completely asleep still parts of it are resting and whatever action and behaviors have to be done they have to be undertaken with limited abilities. So zombies have to attack people but with a lack of proper muscle tone - in dreams we actually have motor paralysis - which makes them totter and move as if a ton of weight is on their shoulders and their feet are shackled. All their motor actions lack smoothness and their brain seems to function like a lobectomy has been done to it. But that is how the brain does function during dreams where verbal, conceptual and abstract forms of thinking are resting/sleeping and the unsatisfied wishes and their satisfaction have to be given expression through visual imagery alone. So the dreams find it easier to give representation to one's ambivalence about attacking others - the patient wanted to attack men out of jealousy but also saw that giving expression to such evil impulses was wrong and part of her mind did not want to do so - by making use of the limited activity of the brain during dreaming and showing the evil being carried out by idiotic semi-humans - the zombies. While the zombies do not carry their evil intentions smoothly because of the ambivalence they never die but keep coming on and on because the evil in us despite our best intention to extinguish, or at least to give no expression to it, persists on and on and can never be completely eliminated.

In this particular dream the zombies were not acting like morons with cerebral palsy because her attitude towards men was changing and it was with love she was approaching them and hence the zombies were biting her back too with love and with absence of ambivalence there was no need for the zombies to groan, lurch, totter and fall all over the place.

One cannot leave the subject of zombies without making a remark upon the frequency with which psychiatric patients complain that the medications you are prescribing them has turned them into zombies. Now our evil impulses which remain in check during the day because we are conscious and alert and under pressure from people around us, during the night, in dreams, can emerge as zombies because parts of the brain are asleep. Is it possible that psychiatric medications do the same: put parts of our brain in to sleep mode and so we feel  we are in a dream state and are more "living-dead" than truly alive? It also raises the question whether the  modus operandi of psychotropic medications is not to put aspects of our brain to sleep so other aspects can  find expression without inhibitions.