Sigmund Freud (1856–1939). Selected Papers on Hysteria and Other Psychoneuroses. 1912.
Chapter IV. The Psychotherapy of Hysteria
We furthermore attempted to explain how our psychotherapeutic method acts. “It does away with the effects of the original not ab-reacted to ideas by affording an outlet to the suppressed affect through speech. It brings it into associative correction by drawing it into normal consciousness (in mild hypnosis), or it is done away with through the physician’s suggestion just as happens in somnambulism with amnesia” (p. 13).
Although the essential features of this method have been enumerated in the preceding pages, a repetition is unavoidable, and I shall now attempt to show connectedly how far-reaching this method is, its superiority over others, its technique, and its difficulties.
In attempting to use Breuer’s method of treating hysterical symptoms in a great number of patients by investigation and ab-reaction in hypnosis, I encountered two obstacles, the pursuit of which led me to change the technique as well as the conception. (1) Not all persons were hypnotizable who undoubtedly showed hysterical symptoms, and in whom there most probably existed the same psychic mechanism. (2) I had to question what essentially characterizes hysteria, and in what it differs from other neuroses.
How I overcame the first difficulty, and what it taught me, I will show later. I will first state what position I have taken in my daily practice towards the second problem. It is very difficult to examine a case of neurosis before it has been subjected to a thorough analysis, such as would result only through the application of Breuer’s method. But before we have such a thorough knowledge we are obliged to decide upon the diagnosis and kind of treatment. Hence the only thing remaining for me was to select such cases for the cathartic method which could, for the time being, be diagnosed as hysteria, and which showed some or many stigmata, or the characteristic symptoms of hysteria. Yet it sometimes happened that in spite of the diagnosis of hysteria the therapeutic results were very poor, and even the analysis revealed nothing of importance. At other times I attempted to treat cases which no one took for hysteria by Breuer’s method, and I found that I could influence them, and even cure them. Such, for example, was my experience with obsessions, the real obsessions of Westphal’s type, cases which did not show a single feature of hysteria. Thus the psychic mechanism revealed in the “Preliminary Communication” could not be pathognomonic of hysteria. Nor could I for the sake of this mechanism throw so many neuroses into the same pot with hysteria. From all the investigated doubts I finally seized upon a plant to treat all the other neuroses in question just like hysteria, to investigate the etiology and the form of psychic mechanisms, and to leave the diagnosis of hysteria to be dependent upon the result of this investigation.
It thus happened that, proceeding from Breuer’s methods, I occupied myself mostly with the etiology and the mechanism of the neuroses. After a relatively brief period I was fortunate in obtaining useful results. I then became cognizant of the fact that if we may speak of a reason for the acquirement of neuroses the etiology must be sought for in the sexual moments. This agrees with the fact that, generally speaking, various sexual moments may also produce various pictures of neurotic disease. Similarly we now venture to employ the etiology for the characteristics of the neuroses, and build up a sharp line of demarcation between the morbid pictures of the neuroses. If the etiological characters constantly agreed with the clinical ones, this was justified.
In this way it was found that neurasthenia really corresponds to a monotonous morbid picture in which, as shown by the analysis, “psychic mechanisms” play no part. From neurasthenia we sharply distinguished the compulsion neurosis (Zwangsneurose) [obsessions, doubts, impulses], the neurosis of the genuine obsessions, in which we can recognize a complicated psychic mechanism, an etiology resembling the one of hysteria, and a far reaching possibility of an involution by psychotherapy. On the other hand it seemed to me undoubtedly imperative to separate from neurasthenia a neurotic symptom complex which depends on a totally divergent, strictly speaking, on a contrary etiology. The partial symptoms of this complex have been recognized by E. Hecker as having a common character. They are either symptoms, or equivalents, or rudiments of anxiety manifestations, and it is for that reason that this complex, so different from neurasthenia, was called by me anxiety neurosis. I maintain that it originates from an accumulation of physical tension which is in turn of a sexual origin. This neurosis, too, has no psychic mechanism, but regularly influences the psychic life, so that among its regular manifestations we have anxious expectation, phobias, hyperesthesias to pain, and other symptoms. This anxiety neurosis, as I take it, certainly corresponds in part to the neurosis called hypochondria, which in some features resembles hysteria and neurasthenia. Yet in none of the earlier works can I consider the demarcation of this neurosis as correct, and moreover, I find that the usefulness of the name hypochondria is impaired by its close relation to the symptom of “nosophobia.”
After I had thus constructed for myself the simple picture of neurasthenia, anxiety neuroses, and obsessions, I turned my attention to the commonly occurring cases of neuroses which enter into the diagnosis of hysteria. I now said to myself that it would not do to mark a neurosis as hysterical on the whole, merely because its symptom complex evinced some hysterical signs. I could readily explain this practice by the fact that hysteria is the oldest, the most familiar, and the most striking neurosis under consideration, but still it was an abuse which allowed the placing of many features of perversion and degeneration under the caption of hysteria. Whenever a hysterical symptom, such as anesthesia or a characteristic attack, could he discovered in a complicated case of psychic degeneration, the whole thing was called “hysteria,” and hence one could naturally find united under this same trade mark the worst and most contradictory features. As certain as this diagnosis was incorrect it is also certain that our classification must be made from the neurotic standpoint, and as we know neurasthenia, anxiety neurosis, and similar conditions in the pure state, there is no need of overlooking them in combination.
It seemed therefore that the following conception was more warrantable. The neuroses usually occurring are generally to be designated as “mixed.” Neurasthenia and anxiety neurosis can be found without effort in pure forms, and most frequently in young persons. Pure cases of hysteria and compulsion neurosis “Zwangsneurose” (obsessions, doubts, impulses) are rare, they are usually combined with an anxiety neurosis. This frequent occurrence of mixed neuroses is due to the fact that their etiological moments are frequently mixed, now only accidentally, and now in consequence of a causal relation between the processes which give rise to the etiological moments of the neuroses. This can be sustained and proven in the individual cases without any difficulty. But it follows from this that it is hardly possible to take hysteria out of connection with the sexual neuroses, that hysteria as a rule presents only one side, one aspect of the complicated neurotic case, and that only, as it were, in the borderline case can it be found and treated as an isolated neurosis. In a series of cases we can perhaps say a potiori fit denominatio.
I shall now examine the cases reported to see whether they speak in favor of my conception of the clinical dependence of hysteria. Breuer’s patient, Anna O., seems to contradict this and exemplifies a pure hysterical disease. Yet this case which became so fruitful for the knowledge of hysteria was never considered by its observer under the guise of a sexual neurosis and hence cannot at present be utilized as such. When I began to analyze the second patient, Mrs. Emmy v. N., the idea of a sexual neurosis on a hysterical basis was far from my mind. I had just returned from the Charcot school, and considered the connection of hysteria with the sexual theme as a sort of insult—just as my patients were wont to do. But when I today review my notes on this case there is absolutely no doubt that I have to consider it as a severe case of anxiety neurosis with anxious expectations and phobias, which was due to sexual abstinence and was combined with hysteria.
The third case. Miss Lucy R., could perhaps be called the first borderline case of pure hysteria. It is a short episodic hysteria based on an unmistakably sexual etiology. It corresponds to an anxiety neurosis in an over-ripe, amorous girl, whose love was too rapidly awakened through a misunderstanding. Yet the anxiety neurosis could either not be demonstrated or had escaped me. Case IV, Katharina, is really a model of what I have called virginal anxiety; it is a combination of an anxiety neurosis and hysteria, the former produces the symptoms, while the latter repeats them and works with them. At all events, it is a typical case of many juvenile neuroses called “hysteria.” Case V, Miss Elisabeth v. R., was again not investigated as a sexual neurosis. I could only suspect that there was a spinal neurasthenia at its basis but I could not confirm it. I must, however, add that since then pure hysterias have become still rarer in my experience. That in grouping together these four cases of hysteria I could disregard in the discussion the decisive factors of sexual neuroses was due to the fact that they were older cases in which I had not as yet carried out the purposed and urgent investigation for the neurotic sexual subsoil. Moreover the reason for my reporting four instead of twelve cases of hysteria, the analysis of which would have confirmed our claims of psychic mechanism for hysterical phenomena, is due to one circumstance, namely that the analysis of these cases would have simultaneously revealed them as sexual neuroses, though surely no diagnostician would have denied them the name “hysteria.” However, the discussion of such sexual neuroses would have overstepped the limits of our joint publication.
I do not wish to be misunderstood and give the impression that I refuse to accept hysteria as an independent neurotic affection, that I conceive it only as a psychic manifestation of the anxiety neurosis, that I ascribe to it “ideogenous” symptoms only, and that I attribute the somatic symptoms, like hysterogenic points and anesthesias to the anxiety neurosis. None of these statements are true. I believe that hysteria, purified of all admixtures, can be treated independently in every respect except in therapy. For in the treatment we deal with a practical purpose, namely, we have to do away with the whole diseased state, and even if the hysteria occurs in most cases as a component of a mixed neurosis, the case merely resembles a mixed infection where the task is to preserve life, and not merely to combat the effect of one inciting cause of the disease.
I, therefore, find it important to separate the hysterical part in the pictures of the mixed neuroses from neurasthenia, anxiety neurosis, etc., for after this separation I can express concisely the therapeutic value of the cathartic method. I would venture to assert that—principally—it can readily dispose of any hysterical symptom, whereas, as can be easily understood, it is perfectly powerless in the presence of neurasthenic phenomena, and can only seldom, and through detours, influence the psychic results of the anxiety neurosis. Its therapeutic efficacy in the individual case will depend on whether or not the hysterical components of the morbid picture can claim a practical and significant position in comparison to the other neurotic components.
Another limitation placed on the efficacy of the cathartic method we have already mentioned in our “Preliminary Communication.” It does not influence the causal determinations of hysteria, and hence it can not prevent the origin of new symptoms in the place of those removed. Hence, on the whole, I must claim a prominent place for our therapeutic method in the realm of the therapy of neuroses, but I would caution against attaching any importance to it, or putting it into practice outside of this connection. As I am unable to give here a “Therapy of Neuroses” as would be required by the practicing physician, the preceding statements are put on a level with the deferred reference to a later communication; still, for purposes of discussion and elucidation, I can add the following remarks:
1. I do not claim that I have actually removed all the hysterical symptoms which I have undertaken to influence by the cathartic method, but I believe that the obstacles were due to the personal circumstances of the cases, and not to the general principles. In passing sentence, these cases of failure may be left out of consideration, just as the surgeon puts aside all cases who die as a result of narcosis, hemorrhage, accidental sepsis, etc., when deciding upon a new technique. I will again consider the failures of such origin in my later discussions on the difficulties and drawbacks of this method.
2. The cathartic method does not become valueless simply because it is symptomatic and not causal. For a causal therapy is really in most cases only prophylactic; it stops the further progress of the injury, but it does not necessarily remove the products which have already resulted from it. To do this it requires, as a rule, a second agent, and in cases of hysteria the cathartic method is really unsurpassable for such purposes.
3. Where the period of hysterical production, or the acute hysterical paroxysm, has subsided, and the only remnant manifestations left are hysterical symptoms, the cathartic method fulfills all indications, and achieves a full and lasting success. Such a favorable constellation for the therapy does not seldom result on the basis of the sexual life, in consequence of the marked fluctuations in the intensity of the sexual desire and the complications of the required determination for a sexual trauma. Here the cathartic method accomplishes all that is required of it, for the physician can not resolve to change a hysterical constitution. He must rest content if he can remove the disease for which such a constitution shows a tendency, and which can arise through the assistance of external determinants. He must be satisfied if the patient will again become capacitated. Moreover, he can have some hopes for the future, if the possibility of a relapse be considered, for he knows the main character of the etiology of the neuroses, namely, that their origin is mostly overdetermined, and that many moments must unite to produce this result. He can hope that this union will not take place very soon, if individual etiological moments remain in force.
It may be argued that in such subsided cases of hysteria the remaining symptoms would spontaneously disappear without anything else, but this can be answered by the fact that such spontaneous cures very often terminate neither rapidly nor fully, and that the cure will be extraordinarily advanced by the treatment. Whether the cathartic treatment cures only that which is capable of spontaneous recovery, or incidentally also, that which would not cease spontaneously, that question may surely be left open for the present.
4. Where we encounter an acute hysteria during the most acute production of hysterical symptoms, and the consecutive overwhelming of the ego by the morbid products (hysterical psychosis), even the cathartic method will change little the expression and course of the disease. One finds himself in the same position to the neurosis as the doctor to an acute infectious disease. For some time past, now beyond the reach of influence, the etiological moments exerted a sufficient amount of effect, which becomes manifest after overcoming the interval of incubation. The affection can not be warded off, it has to run its course, but meanwhile one must bring about the most favorable conditions for the patient. If during such an acute period one can remove the morbid products, the newly formed hysterical symptoms, it may be expected that their places will be taken by new ones. The physician will not be spared the depressing impression of fruitless effort, the enormous expenditure of exertion, and the disappointment of the relatives, to whom the idea of the necessary duration of time of an acute neurosis is hardly as familiar as in the analogous case of an acute infectious disease; these, and many other things, will probably make most impossible the consequent application of the cathartic method in the assumed case. Nevertheless, it still remains to be considered whether, even in an acute hysteria, the frequent removal of the morbid products does not exercise a curative influence by supporting the normal ego which is occupied with the defense, and thus preventing it from merging into a psychosis or into ultimate confusion.
That the cathartic method can accomplish something, even in an acute hysteria, and that it can even reduce the new productions of the morbid symptoms quite practically and noticeably, is undoubtedly evident from the case of Anna O., in which Breuer first learned to exercise this process.
5. Where we deal with chronic progressive hysterias with moderate or continued productions of hysterical symptoms, we learn to regret the lack of a causally effective therapy, but we also learn to value the indications of the cathartic method as a symptomatic remedy. We then deal with an injury produced by an etiology which continues to act chronically. We have to strengthen the capacity for resistance of the nervous system of our patient, and we must bear in mind that the existence of an hysterical symptom signifies a weakening of resistance of the nervous system, and represents a predisposing moment. From the mechanism of monosymptomatic hysteria we know that a new hysterical symptom generally originates as an addition to and as an analogy of one already in existence. The location once penetrated represents the weak spot which can be penetrated again. The split off psychic group plays the part of the provoking crystal from which a formerly omitted crystallization emerges with great facility. To remove the already existing symptoms, to do away with the psychic alterations lying at their basis, is the return to the patients the full measure of their resistance capacity, with which they are successfully able to resist the noxious influences. One can do a great deal for the patient by such long continued watchfulness and occasional “chimney-sweeping.”
6. I still have to mention the apparent contradiction arising between the admission that not all hysterical symptoms are psychogenic, and the assertion that they can all be removed by psychotherapeutic procedures. The solution lies in the fact that some of these non-psychogenic symptoms, though they represent morbid symptoms, as, for instance, the stigmata, should nevertheless not be designated as affections, and hence it cannot be practically noticed even if they remain after the treatment is finished. Other symptoms of a similar nature seem to be taken along indirectly by the psychogenic symptoms, for indirectly they really depend on some psychic causation.
I must mention still another gain in the application of this method. No severe case of complicated neurosis, with either an excessive or slight tinge of hysteria can better be explained than by subjecting it to an analysis by Breuer’s method. In making this analysis I find that whatever shows the hysterical mechanism disappears first, while the rest of the manifestations I meanwhile learn to interpret and refer to their etiology. I thereby gained the essential factors indicated by the instrument of the therapy of the neurosis in question. When I think of the usual differences between my opinion of a case of neurosis before and after such an analysis, I am almost tempted to maintain that the analysis is indispensable for the knowledge of a neurotic disease. I have furthermore made it a practice of applying the cathartic psychotherapy in conjunction with a rest cure, which when required is changed to a full Weir-Mitchell treatment. This advantage lies in the fact that, on the one side I avoid the very disturbing intrusion of new psychic impressions produced during psychotherapy; on the other hand, I exclude the monotony of the Weir-Mitchell treatment, during which the patient not seldom merges into harmful reveries. One might expect that the very considerable psychic labor often imposed upon the patient during the cathartic cure, and the excitement resulting from the reproduction of traumatic events, would run counter to the sense of the Weir-Mitchell rest cure, and would prevent the successes which one is wont to obtain from it. But the contrary happens; through the combination of the Breuer and the Weir-Mitchell therapy, we obtain all the physical improvements which we expect from the latter, and such marked psychic improvement as never occurs in the rest cure without psychotherapy.
The reason why one person is hypnotizable and another not I could no more explain than others, and hence I could not start on a causal way towards the removal of the difficulties. I also observed that in some patients the obstacle was still more marked, as they even refused to submit to hypnosis. The idea then occurred to me that both cases might be identical, and that in both it might merely be an unwillingness. Those who entertain a psychic inhibition against hypnotism are not hypnotizable, it makes no difference whether they utter their unwillingness or not. It is not fully clear to me whether I can firmly adhere to this conception or not.
It was, therefore, important to avoid hypnotism and yet to obtain the pathogenic reminiscences. Thus I attained in the following manner:
On asking my patients during our first interview whether they remembered the first motive for the symptom in question, some said that they knew nothing, while others thought of something which they designated as an indistinct recollection, yet were unable to pursue it. I then followed Bernheim’s example of awakening the apparently forgotten impressions obtained during somnambulism (see the case of Miss Lucy). I urged them by assuring them that they did know it, and that they will recall it, etc., and thus some thought of something, while in others the recollections went further. I became still more pressing, I ordered the patient to lie down and voluntarily shut his eyes so as to “concentrate” his mind, causing thereby at least a certain similarity to hypnosis, and I then discovered that without any hypnosis there emerged new and retrospective reminiscences which probably belonged to our theme. Through such experiences I gained the impression that through urging alone it would really be possible to bring to light the definitely existing pathogenic series of ideas; and as this urging necessitated much exertion on my part, and showed me that I had to overcome a resistance, I, therefore, formulated this whole state of affairs into the following theory: Through my psychic work I had to overcome a psychic force in the patient which opposed the pathogenic idea from becoming conscious (remembered). It then became clear to me that this must really be the same psychic force which assisted in the origin of the hysterical symptom, and at that time prevented the pathogenic idea from becoming conscious. What kind of effective force could here be assumed, and what motive could have brought it into activity? I could easily formulate an opinion, for I already had some complete analyses at my disposal in which I found examples of pathogenic, forgotten, and repressed ideas. From these I could judge the general character of such ideas. They were altogether of a painful nature adapted to provoke the affects of shame, reproach, of psychic pain, and the feeling of injury; they were altogether of that kind which one would not like to experience and prefers to forget.
From all these the thought of defense resulted as if simultaneously. Indeed, it is generally admitted by all psychologists that the assumption of a new idea (assumption in the sense of belief, judgment of reality), depends on the mode and drift of the ideas already united in the ego. For the process of the censor, to which the newly formed ideas are subjected, special technical names have been created. An idea entered into the ego of the patient which proved to be unbearable and evoked a power of repulsion on the part of the ego, the purpose of which was a defense against this unbearable idea. This defense actually succeeded, and the idea concerned was crowded out of consciousness and out of the memory, so that its psychic trace could not apparently be found. Yet this trace must have existed. When I made the effort to direct the attention to it, I perceived as a resistance the same force which showed itself as repulsion in the genesis of the symptom. If I could now make it probable that the idea became pathogenic in consequence of the exclusion and repression, the chain would seem complete. In many epicrises of our histories, and in a small work concerning the defense neuropsychoses (1894), I have attempted to indicate the psychological hypotheses with the help of which this connection also—the fact of conversion—can be made clear.
Hence, a psychic force, the repugnance of the ego, has originally crowded the pathogenic idea from the association, and now opposes its return into the memory. The not knowing of the hysterics was really a—more or less conscious—not willing to know, and the task of the therapeutist was to overpower this resistance of association by psychic labor. Such accomplishment is, above all, brought about by “urging,” that is, by applying a psychic force in order to direct the attention of the patient on the desired traces of ideas. It does not, however, stop here, but as I will show, it assumes new form in the course of the analysis, and calls to aid more psychic forces.
I shall above all, still linger at “the urging.” One cannot go very far with such simple assurances as, “You do know it, just say it,” or “It will soon come to your mind.” After a few sentences the thread breaks, even in the patient who is in a state of concentration. We must not however, forget that we deal everywhere here with a quantitative comparison, with the struggle between motives of diverse force and intensity. The urging of the strange and inexperienced physician does not suffice for the “association resistance” in a grave hysteria. One must resort to more forceful means.
In the first place I make use of a small technical artifice. I inform the patient that I will in the next moment exert pressure on his forehead, I assure him that during this pressure he will see some reminiscence in the form of a picture, or some thought will occur to him, and I oblige him to communicate to me this picture or this thought, no matter what it may be. He is not supposed to hold it back because he may perhaps think that it is not the desired or the right thing, or because it is too disagreeable to say. There should be neither criticism nor reserve on account of affect or disregard. Only thus could we find the things desired, and only thus have we unfailingly found them. I then exert pressure for a few seconds on the forehead of the patient lying in front of me, and after stopping the pressure, I ask in a calm tone, as if any disappointment is out of the question, “What have you seen?” or, “What occurred to your mind?”
This method taught me a great deal and led me to the goal every time. Of course I know that I can substitute this pressure on the forehead by any other sign, or any other physical influence, but as the patient lies before me the pressure on the forehead, or the grasping of his head between my two hands, is the most suggestive and most convenient thing that I could undertake for this end. To explain the efficacy of this artifice, I may perhaps say that it corresponds to a “momentary reenforced hypnosis”; but the mechanism of hypnosis is so enigmatical to me that I would not like to refer to it as an explanation. I rather think that the advantage of the process lies in the fact that through it I dissociate the attention of the patient from his conscious quest and reflection, in brief, from everything upon which his will can manifest itself. This resembles the process of staring at a crystal globe, etc. The fact, that under the pressure of my hand there always appears that which I am looking for teaches that the supposedly forgotten pathogenic ideas always lie ready, “close by,” being attainable through easily approachable associations, and all that is necessary is to clear away some obstacle. This obstacle again seems to be the person’s will, and different persons learn to discard their premeditations and to assume a perfectly objective attitude toward the psychic processes within them.
It is not always a “forgotten” reminiscence which comes to the surface under the pressure of the hand; in the rarest cases the real pathogenic reminiscences can be superficially discovered. More frequently an idea comes to the surface which is a link between the starting idea and the desired pathogenic one of the association chain, or it is an idea forming the starting point of a new series of thoughts and reminiscences, at the end of which the pathogenic idea exists. The pressure, therefore, has really not revealed the pathogenic idea, which, if torn from its connections without any preparation, would be incomprehensible; but it has shown the way to it, and indicated the direction towards which the investigation must proceed. The idea which is at first awakened through the pressure may correspond to a familiar reminiscence which was never repressed. If the connection becomes torn on the road to the pathogenic idea, all that is necessary for the reproduction of a new orientation and connection is a repetition of the procedure, that is, of the pressure.
In still other cases the pressure of the hand awakens a reminiscence well known to the patient, which appearance, however, causes him surprise because he had forgotten its relation to the starting idea. In the further course of the analysis this relation becomes clear. From all these results of the pressure one receives a delusive impression of a superior intelligence external to the patient’s consciousness, which systematically holds a large psychic material for definite purposes, and has provided an ingenious arrangement for its return into consciousness. I presume, however, that this unconscious second intelligence is really only apparent.
In every complicated analysis one works repeatedly, nay continuously, with the help of this procedure (pressure on the forehead), which leads us from the place where the patient’s conscious reconductions become interrupted, showing us the way over reminiscences which remained known, and calling our attention to connections which have merged into forgetfulness. It also evokes and connects memories which have for years been withdrawn from the association, but can still be recognized as memories; and finally, as the highest performance of reproduction, it causes the appearance of thoughts which the patient never wishes to recognize as his own, which he does not remember, although he admits that they are inexorably demanded by the connection, and is convinced that just these ideas cause the termination of the analysis and the cessation of the symptoms.
I will now attempt to give a series of examples showing the excellent achievements of this procedure. I treated a young lady who suffered for six years from an intolerable and protracted nervous cough, which apparently was nurtured by every common catarrh, but must have had its strong psychic motives. Every other remedy had long since shown itself to be powerless, and I therefore attempted to remove the symptom by psychoanalysis. All that she could remember was that the nervous cough began at the age of fourteen while she boarded with her aunt. She remembered absolutely no psychic excitement during that time, and did not believe that there was a motive for her suffering. Under the pressure of my hand, she at first recalled a large dog. She then recognized the memory picture; it was her aunt’s dog which was attached to her, and used to accompany her everywhere, and without any further aid it occurred to her that this dog died and that the children buried it solemnly; and on the return from this funeral her cough appeared. I asked her why she began to cough, and after helping her with the pressure, the following thought occurred to her: “Now I am all alone in this world; no one loves me here; this animal was my only friend, and now I have lost it.” She then continued her story. “The cough disappeared when I left my aunt, but reappeared a year and a half later.”—“What was the reason for it?”—“I do not know.”—I again exerted some pressure on the forehead, and she recalled the news of her uncle’s death during which the cough again manifested itself, and also recalled a train of thought similar to the former. The uncle was apparently the only one in the family who sympathized with and loved her. That was, therefore, the pathogenic idea: “People do not love her; everybody else is preferred; she really does not deserve to be loved,” etc. To the idea of love there clung something which caused a marked resistance to the communication. The analysis was interrupted before this explanation.
Before I could continue the analysis, I had occasion to talk to a colleague, who, in former years, was my patient’s family physician. From him I obtained the following explanation: At the time that he treated the mature and physically very well developed girl for these first attacks, he was struck by the excessive affection in the relations between her and her governess. He became suspicious and caused the grandmother to watch these relations. After a short while the old lady informed him that the governness was wont to pay nightly visits to the child’s bed, and that quite regularly after such visits the child was found in the morning in an attack. She did not hesitate to bring about the quiet removal of this corruptress of youth. The children, as well as the mother, were made to believe that the governness left the house in order to get married.
The treatment, which was above all successful, consisted in informing the young woman of the explanations given to me.
On asking the lady whether she had seen or recalled anything under the pressure of my hand, she answered, “Neither, but a word suddenly occurred to me.”—“A single word?”—“Yes, but it is too foolish.”—“Just tell it.”—“Teacher.”—“Nothing more?”—“No.” I exerted pressure a second time, and again a single word flashed through her mind: “Shirt.”—I now observed that we have dealt with a new mode of replying, and by repeated pressure I evoked the following apparently senseless series of words: Teacher—shirt—bed—city—wagon. I asked, “What does all that mean?” She reflected for a moment, and it then occurred to her that “it can only refer to this one incident which now comes to my mind. When I was ten years old my older sister of twelve had an attack of frenzy one night, and had to be bound, put in a wagon and taken to the city. I remember distinctly that it was the teacher who overpowered her and accompanied her to the asylum.”—We then continued this manner of investigation, and received from our oracle another series of words which, though we could not altogether interpret, could nevertheless be used as a continuation of the story, and as an appendix to a second. The significance of this reminiscence was soon clear. The reason why her sister’s illness made such an impression on her was because they both shared a common secret. They slept in the same room, and one night they both submitted to a sexual assault by a certain man. In discovering this sexual trauma of early youth, we revealed not only the origin of the first obsession but also the trauma which later acted pathogenically.—The peculiarity of this case lies only in the appearance of single catch words which we had to elaborate into sentences, for the irrelevance and incoherence found in these oracle like uttered words adhere to all ideas and scenes which generally occur as a result of pressure. On further investigation it is regularly found that the seemingly disconnected reminiscences are connected by close streams of thought, and that they lead quite directly to the desired pathogenic moment.
With pleasure do I therefore recall a case of analysis in which my confidence in the results of pressure was splendidly justified. A very intelligent, and apparently very happy, young woman consulted me for persistent pain in her abdomen which yielded to no treatment. I found that the pain was situated in the abdominal wall and was due to palpable muscular hardening, and I ordered local treatment.
After months I again saw the patient who said that “the former pain disappeared after following the treatment and remained away a long time, but now it has reappeared as a nervous pain. I recognize it by the fact that I do not perceive it now on motion as before, but only during certain hours, as for example, in the morning on awakening, and during certain excitements.” The patient’s diagnosis was quite correct. It was now important to discover the cause of this pain, but in this she could not assist me in her uninfluenced state. When, in a state of concentration and under the pressure of my hand, I asked her whether anything occurred to her, or whether she saw anything, she began to describe her visual pictures. She saw something like a sun with rays, which I naturally had to assume to be a phosphene produced by pressure on the eyes. I expected that the useful pictures would follow, but she continued to see stars of a peculiar pale blue light, like moonlight, etc., and I believed that she merely saw glittering, shining, and twinkling spots before the eyes. I was already prepared to add this attempt to the failures, and I was thinking how I could quietly withdraw from this affair, when my attention was called to one of the manifestations which she described. She saw a big black cross which was inclined, the edges of which were surrounded by a subdued moonlike light in which all the pictures thus far seen were shining, and upon the arm there flickered a little flame that was apparently no longer a phosphene. I continued to listen. She saw numerous pictures in the same light, peculiar signs resembling somewhat sanscrit. She also saw figures like triangles, among which there was one big triangle, and again the cross. I now thought of an allegorical interpretation, and asked, “What does this cross mean?”—“It is probably meant to interpret pain,” she answered. I argued, saying, that “by cross one usually understands a moral burden,” and asked her what was hidden behind that pain. She could not explain that and continued looking. She saw a sun with golden rays which she interpreted as God, the primitive force; she then saw a gigantic lizard which she examined quizzically but without fear; then a heap of snakes, then another sun but with mild silvery rays, and in front of it, between her own person and this source of light, there was a barrier which concealed from her the center of the sun.
I knew for some time that we dealt here with allegories, and I immediately asked for an explanation of the last picture. Without reflecting she answered: “The sun is perfection, the ideal, and the barrier represents my weaknesses and failings which stand between me and the ideal.”—“Indeed, do you reproach yourself? Are you dissatisfied with yourself?”—“Yes.”—“Since when?”—“Since I became a member of the Theosophical Society and read the writings edited by it. I have always had a poor opinion of myself.”—“What was it that made the last strongest impression upon you?”—“a translation from the sanscrit which now appears in serial numbers.” A minute later I was initiated into her mental conflicts, and into her self reproaches. She related a slight incident which gave occasion for a reproach, and in which, as a result of an inciting conversion, the former organic pain at first appeared. The pictures which I had at first taken for phosphenes were symbols of occultistic streams of thought, perhaps plain emblems from the title pages of occultistic books.
I need only recall the various forms in which this resistance manifested itself. In the first place, the pressure experiment usually fails the first or second time. The patient then expresses himself disappointed, saying, “I believed that some idea would occur to me, but I only thought so; as attentive as I was nothing came.” Such attitudes assumed by the patient are not yet to be counted as a resistance; we usually answer to that, “You were really too anxious, the second time things will come.” And they really come. It is remarkable how completely the patients—even the most tractable and the most intelligent—can forget the agreement which they have previously entered into. They have promised to tell everything that occurs to them under the pressure of the hand, be it closely related to them or not, and whether it is agreeable to them to say it or not; that is, they are to tell everything without any choice, or influence by critique or affect. Yet they do not keep their promise, it is apparently beyond their powers. The work repeatedly stops, they continue to assert that this time nothing came to their mind. One needs not believe them, and one must always assume, and also say, that they hold back something because they believe it to be unimportant, or perceive it as painful. One must insist, repeat the pressure, and assume an assured attitude until one really hears something. The patient then adds, “I could have told you that the first time.”—“Why did you not say it?”—“I could not believe that that could be it. Only after it returned repeatedly have I decided to tell it”; or, “I had hoped that it would not be just that, that I could spare myself from saying it, but only after it could not be repressed have I noticed that I could not avoid it.”—Thus the patient subsequently betrays the motives of a resistance which he did not at first wish to admit. He apparently could not help offering resistances.
It is remarkable under what subterfuges these resistances are frequently hidden. “I am distracted today”; “the clock or the piano playing in the next room disturbs me,” they say. I became accustomed to answer to that, “Not at all, you simply struck against something that you do not willingly wish to say. That does not help you at all. Just stick to it.”—The longer the pause between the pressure of my hand and the utterance of the patient, the more suspicious I become, and the more is it to be feared that the patient arranges what comes to his mind, and distorts it in the reproduction. The most important explanations are frequently ushered in as superfluous accessories, just as the princes of the opera who are dressed as beggars. “Something now occurred to me, but it has nothing to do with it. I only tell it to you because you wish to know everything.” With this introduction we usually obtain the long desired solution. I always listen when I hear a patient talk so lightly of an idea. That the pathogenic idea should appear of so little importance on its reappearance is a sign of the successful defense. One can infer from this of what the process of defense consisted. Its object was to make a weak out of a strong idea, that is, to rob it of its affect.
Among other signs the pathogenic memories can also be recognized by the fact that they are designated by the patient as unessential, and yet are only uttered with resistance. There are also cases where the patient seeks to disavow the recollections, even while they are being reproduced, with such remarks as these: “Now something occurred to me, but apparently you talked it into me”; or, “I know what you expect to this question, you surely think that I thought of this and that.” An especially clever way of shifting is found in the following expression: “Now something really occurred to me, but it seems to me as if I added it, and that it is not a reproduced thought.”—In all these cases I remain inflexibly firm, I admit none of these distinctions, but explain to the patient that these are only forms and subterfuges of the resistance against the reproduction of a recollection which in spite of all we are forced to recognize.
One generally experiences less trouble in the reproduction of pictures than thoughts. Hysterical patients who are usually visual are easier to manage than patients suffering from obsessions. Once the picture emerges from the memory we can hear the patient state that as he proceeds to describe it, it proportionately fades away and becomes indistinct; the patient wears it out, so to speak, by transforming it into words. We then orient ourselves through the memory picture itself in order to find the direction towards which the work should be continued. We say to the patient, “Just look again at the picture, has it disappeared?”—“As a whole, yes, but I still see this detail.”—“Then this must have some meaning, you will either see something new, or this remnant will remind you of something.” When the work is finished the visual field becomes free again, and a new picture can be called forth; but at other times such a picture, in spite of its having been described, remains persistently before the inner eye of the patient, and I take this as a sign that he still has something important to tell me concerning its theme. As soon as this has been accomplished, the picture disappears like a wandering spirit returning to rest.
It is naturally of great value for the progress of the analysis to carry our point with the patient, otherwise we have to depend on what he thinks is proper to impart. It, therefore, will be pleasant to hear that the pressure procedure never failed except in a single case which I shall discuss later, but which I can now characterize by the fact that there was a special motive for the resistance. To be sure, it may happen under certain conditions that the procedure may be applied without bringing anything to light; as, for example, we may ask for the further etiology of a symptom when the same has already been exhausted; or, we may investigate for the psychic genealogy of a symptom, perhaps a pain, which really was of somatic origin. In these cases the patient equally insists that nothing occurred to him, and he is right. We should strive to avoid doing an injustice to the patient by making it a general rule not to lose sight of his features while he calmly lies before us during the analysis. One can then learn to distinguish, without any difficulty, the psychic calm in the real nonappearance of a reminiscence from the tension and emotional signs under which the patient labors in trying to disavow the emerging reminiscences for the purpose of defense. The differential diagnostic application of the pressure procedure is really based on such experiences.
We can see, therefore, that even with the help of the pressure procedure the task is not an easy one. The only advantage gained is the fact that we have learned from the results of this method in what direction to investigate, and what things we have to force upon the patient. For some cases that suffices, for the question is really to find the secret, and tell it to the patient, so that he is usually then forced to relinquish his resistance. In other cases more is necessary; here the surviving resistance of the patient manifests itself by the fact that the connections become torn, the solutions do not appear, and the recalled pictures come indistinctly and incompletely. On reviewing, at a later period, the earlier results of an analysis, we are often surprised at the distorted aspects of all the occurrences and scenes which we have snatched from the patient by the pressure procedure. It usually lacks the essential part, the relations to the person or to the theme, and for that reason the picture remained incomprehensible. I will now give one or two examples showing the effects of such a censoring during the first appearance of the pathogenic memories. The patient sees the upper part of a female body on which a loose covering fits carelessly, only much later he adds to this torso the head, and thereby betrays a person and a relationship. Or, he relates a reminiscence of his childhood about two boys whose forms are very indistinct, and to whom a certain mischievousness was attributed. It required many months and considerable progress in the course of the analysis before he again saw this reminiscence and recognized one of the children as himself and the other as his brother. What means have we now at our disposal to overcome this continued resistance?
We have but few, yet we have almost all those by which one person exerts a psychic influence on the other. In the first place we must remember that psychic resistance, especially of long continuance, can only be broken slowly, gradually, and with much patience. We can also count on the intellectual interest which manifests itself in the patient after a brief period of the analysis. On explaining and imparting to him the knowledge of the marvelous world of psychic processes, which we have gained only through such analysis, we obtain his collaboration, causing him to view himself with the objective interest of the investigator, and we thus drive back the resistance which rests on an affective basis. But finally—and this remains the strongest motive force—after the motives for the defense have been discovered, we must make the attempt to reduce or even substitute them by stronger ones. Here the possibility of expressing the therapeutic activity in formulæ ceases. One does as well as he can as an explainer where ignorance has produced timorousness, as a teacher, as a representative of a freer and more superior world-conception, and as confessor, who through the continuance of his sympathy and his respect, imparts, so to say, absolution after the confession. One endeavors to do something humane for the patient in so far as the range of one’s own personality and the measure of sympathy which one can set apart for the case allows. It is an indispensable prerequisite for such psychic activities to have approximately discovered the nature of the case and the motives of the defense here effective. Fortunately the technique of the urging and the pressure procedure take us just so far. The more we have solved such enigmas the easier will we discover new ones, and the earlier will we be able to manage the actual curative psychic work. For it is well to bear in mind that although the patient can rid himself of an hysterical symptom only after reproducing and uttering under emotion its causal pathogenic impressions, yet the therapeutic task merely consists in inducing him to do it, and once the task has been accomplished there remains nothing for the doctor to correct or abolish. All the contrary suggestions necessary have already been employed during the struggle carried on against the resistance. The case may be compared to the unlocking of a closed door, where, as soon as the door knob has been pressed downward, no other difficulties are encountered in opening the door.
Among the intellectual motives employed for the overcoming of the resistance one can hardly dispense with one affective moment, that is, the personal equation of the doctor, and in a number of cases this alone will be able to break the resistance. The conditions here do not differ from those found in any other branch of medicine, and one should not expect any therapeutic method to fully disclaim the assistance of this personal moment.
I held this distinction as so essential that it has readily induced me to adhere to the formation of the hypnoid-hysteria. It is however remarkable that in my own experience I encountered no genuine hypnoid-hysteria, whatever I treated changed itself into a defense hysteria. Not that I have never dealt with symptoms which manifestly originated in separated conscious states, and therefore were excluded from being accepted into the ego. I found this also in my own cases, but I could show that the so called hypnoid state owed its separation to the fact that a split-off psychic group originated before, through defense. In brief, I cannot suppress the suspicion that hypnoid and defense hysteria meet somewhere at their roots, and that the defense is the primary thing; but I know nothing about it.
Equally uncertain is at present my opinion concerning the retention hysteria in which the therapeutic work is also supposed to follow without any resistance. I had a case which I took for a typical retention hysteria, and I was pleased over the anticipation of an easy and certain success; but this success did not come as easy as the work really was. I therefore presume, and again with all caution appropriate to ignorance, that in retention hysteria, too, we can find at its basis a fragment of defense which has thrust the whole process into hysteria. Let us hope that new experiences will soon decide whether I am running into the danger of one-sidedness and error in my tendency to spread the conception of defense for the whole of hysteria.
The first and strongest impression which one gains through such an analysis is surely the fact that the pathogenic psychic material, apparently forgotten and not at the disposal of the ego, playing no rôle in the association and in memory, still lies ready in some manner and in proper and good order. All that is necessary is to remove the resistances blocking the way. Barring that, everything is known as we know anything else, the proper connections of the individual ideas among themselves and with the nonpathogenic are frequently recalled and are present; they have been produced in their time and retained in memory. The pathogenic psychic material appears as the property of an intelligence which is not necessarily inferior to the normal ego. The semblance of a second personality is often most delusively produced. Whether this impression is justified, whether the arrangements of the psychic material resulting after the adjustment is not transferred back into the time of the disease, these are questions which I do not like to consider in this place. One cannot easily and intuitively describe the experiences resulting from these analyses as if he placed himself in the position, which one can only take a survey of after their disappearance.
The condition is usually not so simple as one represents it in special cases, as, for example, in a single case in which a symptom originates through a serious trauma. We frequently deal not with a single hysterical symptom but with a number of the same which are partially independent of one another and partially connected. We must not expect a single traumatic reminiscence whose nucleus is a single pathogenic idea, but we must be ready to assume a series of partial traumas and a concatenation of pathogenic streams of thought. The monosymptomatic traumatic hysteria is, as it were, an elementary organism, it is a single being in comparison to the complicated structure of a grave hysterical neurosis as is generally encountered.
The psychic material of such hysteria presents itself as a multidimensional formation of at least triple stratification. I hope to be able to soon justify this figurative expression. First of all there is a nucleus of such reminiscences (either experiences or streams of thought) in which the traumatic moment culminated, or in which the pathogenic idea has found its purest formation. Around this nucleus we often find an incredibly rich mass of other memory material which we have to elaborate by the analysis in the triple arrangement mentioned before. In the first place, there is an unmistakable linear chronological arrangement which takes place within every individual theme. As an example of this I can only cite the arrangement in Breuer’s analysis of Anna O. The theme is that of becoming deaf, of not hearing, which then becomes differentiated according to seven determinants, and under each heading there were from ten to one hundred single reminiscences in chronological order. It was as if one should take up an orderly kept record. In the analysis of my patient, Emmy v. N., there were similar if not so many memory subdivisions; they formed quite a general event in every analysis. They always occurred in a chronological order which was as definitely reliable as the serial sequences of the days of the week or the names of the months in psychically normal individuals. They increased the work of the analysis through the peculiarity of reversing the series of their origin in the reproduction; the freshest and the most recent occurrence of the accumulation occurred first as a “wrapper,” and that with which the series really began gave the impression of the conclusion.
The grouping of similar reminiscences in a multiplicity of linear stratifications, as represented in a bundle of documents, in a package, etc., I have designated as the formation of a theme. These themes now show a second form of arrangement. I cannot express it differently than by saying that they are concentrically stratified around the pathogenic nucleus. It is not difficult to say what determines these strata, and according to what decreasing or increasing magnitude this arrangement follows. They are layers of equal resistance tending towards the nucleus, accompanied by zones of similar alteration of consciousness into which the individual themes extend. The most peripheral layers contain those reminiscences (or fascicles) of the different themes which can readily be recalled and were always perfectly conscious. The deeper one penetrates the more difficult it becomes to recognize the emerging reminiscences until one strikes those near the nucleus which the patient disavows, even at the reproduction.
As we shall hear later it is the peculiarity of the concentric stratification of the pathogenic psychic material which gives to the course of such an analysis its characteristic features. We must now mention the third and most essential arrangement concerning which a general statement can hardly be made. It is the arrangement according to the content of thought, the connection through the logical thread reaching to the nucleus which might in each case correspond to a special, irregular, and manifoldly devious road. This arrangement has a dynamic character in contradistinction to both morphological stratifications mentioned before. Whereas, in a specially formed scheme the latter would be represented by rigid, arched, and straight lines, the course of the logical concatenation would have to be followed with a wand, over the most tortuous route, from the superficial into the deep layers and back, generally, however, progressing from the peripheral to the central nucleus, and touching thereby all stations; that is, its movement is similar to the zigzag movement of the knight in the solution of a chess problem.
I will still adhere for a moment to the last comparison in order to call attention to a point in which it does not do justice to the qualities of the thing compared. The logical connection corresponds not only to a zigzag-like devious line, but rather to a ramifying and especially to a converging system of lines. It has a junction in which two or more threads meet only to proceed thence united, and, as a rule, many threads running independently, or here and there connected by by-paths, open into the nucleus. To put it in different words, it is very remarkable how frequently a symptom is manifoldly determined, that is, over-determined.
I will introduce one more complication, and then my effort to illustrate the organization of the pathogenic psychic material will be achieved. It can happen that we may deal with more than one single nucleus in the pathogenic material, as, for example, when we have to analyze a second hysterical outbreak having its own etiology but which is still connected with the first outbreak of an acute hysteria which has been overcome years before. It can readily be imagined what strata and streams of thought must be added in order to produce a connection between the two pathogenic nuclei.
I will still add a few observations to the picture obtained of the organization of the pathogenic material. We have said of this material that it behaves like a foreign body, and that the therapy also acts like the removal of a foreign body from the living tissues. We are now in position to consider the shortcomings of this comparison. A foreign body does not enter into any connection with the layers of tissue surrounding it, although it changes them and produces in them a reactive inflammation. On the other hand, our pathogenic psychic group does not allow itself to be cleanly shelled out from the ego, its outer layers radiate in all directions into the parts of the normal ego, and really belong to the latter as much as to the pathogenic organization. The boundaries between both become purely conventional in the analysis, being placed now here, now there, and in certain locations no demarcation is possible. The inner layers become more and more estranged from the ego without showing a visible beginning of the pathogenic boundaries. The pathogenic organization really does not behave like a foreign body, but rather like an infiltration. The infiltrate must, in this comparison, be assumed to be the resistance. Indeed, the therapy does not consist in extirpating something—psychotherapy cannot do that at present—but it causes a melting of the resistance, and thus opens the way for the circulation into a hitherto closed territory.
(I make use here of a series of comparisons all of which have only a very limited resemblance to my theme, and do not even agree among themselves. I am aware of that, and I am not in danger of over-estimating their value; but, as it is my intention to illustrate the many sides of a most complicated and not as yet depicted idea, I therefore take the liberty of dealing also in the following pages with comparisons which are not altogether free from objections.)
If, after a thorough adjustment, one could show to a third party the pathogenic material in its present recognized, complicated and multidimensional organization, he would justly propound the question, “How could such a camel go through the needle’s eye?” Indeed, one does not speak unjustly of a “narrowing of consciousness.” The term gains in sense and freshness for the physician who accomplishes such an analysis. Only one single reminiscence can enter into the ego-consciousness; the patient occupied in working his way through this one sees nothing of that which follows, and forgets everything that has already wedged its way through. If the conquest of this one pathogenic reminiscence strikes against impediments, as, for example, if the patient does not yield the resistance against it, but wishes to repress or distort it, the strait is, so to speak, blocked; the work comes to a standstill, it cannot advance, and the one reminiscence in the breach confronts the patient until he takes it up into the breadth of his ego. The whole spacially extended mass of the pathogenic material is thus drawn through a narrow fissure and reaches consciousness as if disjointed into fragments or strips, and it is the task of the psychotherapist to recompense it into the conjectured organization. He who desires still more comparisons may think here of a Chinese puzzle.
If one is about to begin an analysis in which one may expect such an organization of the pathogenic material, the following results of experience may be useful: It is perfectly hopeless to attempt to make any direct headway towards the nucleus of the pathogenic organization. Even if it could be guessed the patient would still not know what to start with the explanation given to him, nor would it change him psychically.
There is nothing left to do but follow up the periphery of the pathogenic psychic formation. One begins by allowing the patient to relate and recall what he knows, during which one can already direct his attention, and through the application of the pressure procedure slight resistances may be overcome. Whenever a new way is opened through pressure it can be expected that the patient will continue it for some distance without any new resistance.
After having worked for a while in such manner a coöperating activity is usually manifested in the patient. A number of reminiscences now occur to him without any need of questioning or setting him a task. A way has thus been opened into an inner stratum, within which the patient now spontaneously disposes of the material of equal resistance. It is well to allow him to reproduce for a while without being influenced; of course, he is unable to reveal important connections, but he may be allowed to clear things within the same stratum. The things which he thus reproduces often seem disconnected, but they give up the material which is later revived by the recognized connections.
One has to guard here in general against two things. If the patient is checked in the reproduction of the inflowing ideas, something is apt to be “buried” which must be uncovered later with great effort. On the other hand one must not overestimate his “unconscious intelligence,” and one must not allow it to direct the whole work. If I should wish to schematize the mode of labor, I could perhaps say that one should himself undertake the opening of the inner strata and the advancement in the radial direction, while the patient should take care of the peripheral extension.
The advancement is brought about by the fact that the resistance is overcome in the manner indicated above. As a rule, however, one must at first solve another problem. One must obtain a piece of a logical thread by which direction alone one can hope to penetrate into the interior. One should not expect that the voluntary information of the patient, the material which is mostly in the superficial strata, will make it easy for the analyzer to recognize the locations where it enters into the deep, and to which points the desired connections of thought are attached. On the contrary, just this is cautiously concealed, the assertion of the patient sounds perfect and fixed in itself. One is at first confronted, as it were, by a wall which shuts off every view, and gives no suggestion of anything hidden behind it.
If, however, one views with a critical eye the assertion obtained from the patient without much effort and resistance, one will unmistakably discover in it gaps and injuries. Here the connection is manifestly interrupted and is scantily completed by the patient by an expression conveying quite insufficient information. Here one strikes against a motive which in a normal person would be designated as flimsy. The patient refuses to recognize these gaps when his attention is called to them. The physician, however, does well to seek under these weak points access to the material of the deeper layers and to hope to discover just here the threads of the connections which he traces by the pressure procedure. One, therefore, tells the patient, “You are mistaken, what you assert can have nothing to do with the thing in question; here we will have to strike against something which will occur to you under the pressure of my hand.”
The hysterical stream of thought, even if it reaches into the unconscious, may be expected to show the same logical connections and sufficient causations as those that would be formed in a normal individual. A looseness of these relationships does not lie within the sphere of influence of the neurosis. If the association of ideas of neurotics, and especially of hysterics, makes a different impression, if the relation of the intensities of different ideas does not seem to be explainable here on psychological determinants alone, we know that such manifestations are due to the existence of concealed unconscious motives. Such secret motives may be expected wherever such a deviation in the connection, or a transgression from the normally justified causations can be demonstrated.
To be sure one must free himself from the theoretical prejudice that one has to deal with abnormal brains of dégénerés and deséquilibrés, in whom the freedom of overthrowing the common psychological laws of the association of ideas is a stigma, or in whom a preferred idea without any motive may grow intensively excessive, and another without psychological motives may remain indestructible. Experience shows the contrary in hysteria; as soon as the hidden—often unconsciously remaining—motives have been revealed and brought to account there remains nothing in the hysterical thought connection that is enigmatical and anomalous.
Thus by tracing the breaches in the first statements of the patient, which are often hidden by “false connections,” one gets hold of a part of the logical thread at the periphery, and thereafter continues the route by the pressure procedure.
Very seldom do we succeed in working our way into the inner strata by the same thread, usually it breaks on the way when the pressure fails, giving up either no experience, or one which cannot be explained or be continued despite all efforts. In such a case we soon learn how to protect ourselves from the obvious confusion. The expression of the patient must decide whether one really reached an end or encountered a case needing no psychic explanation, or whether it is the enormous resistance that halts the work. If the latter cannot soon be overcome, it may be assumed that the thread has been followed into a stratum which is as yet impenetrable. One lets it fall in order to grasp another thread which may, perhaps, be followed up just as far. If one has followed all the threads into this stratum, if the knottings have been reached through which no single isolated thread can be followed, it is well to think of seizing anew the resistances on hand.
One can readily imagine how complicated such a work may become. By constantly overcoming the resistance, one pushes his way into the inner strata, gaining knowledge concerning the accumulative themes and passing threads found in this layer; one examines as far as he can advance with the means at hand, and by means of the pressure procedure he gains first information concerning the content of the next stratum.
The threads are dropped, taken up again, and followed until they reach the juncture; they are always retrieved, and by following a memory fascicle one reaches some by-way which finally opens again. In this manner it is possible to leave the work, layer by layer, and advance directly on the main road to the nucleus of the pathogenic organization. Thus the fight is won but not finished. One has to follow up the other threads and exhaust the material; but now the patient helps again energetically, for his resistance has mostly been broken.
In these later stages of the work it is of advantage if one can surmise the connection and tell it to the patient before it has been revealed. If the conjecture is correct the course of the analysis is accelerated, but even an incorrect hypothesis helps, for it urges the patient to participate and elicits from him energetic refutation, thus revealing that he surely knows better.
One, thereby, becomes astonishingly convinced, that it is not possible to press upon the patient things which he apparently does not know, or to influence the results of the analysis by exciting his expectations. I have not succeeded a single time in altering or falsifying the reproductions of memory or the connections of events by my predictions; had I succeeded it surely would have been revealed in the end by a contradiction in the construction. If anything occurred as I predicted, the correctness of my conjecture was always attested by numerous trustworthy reminiscences. Hence, one must not fear to express his opinion to the patient concerning the connections which are to follow; it does no harm.
Another manifestation which can be repeatedly observed refers to the patient’s independent reproductions. It can be asserted that not a single reminiscence comes to the surface during such an analysis which has no significance. An interposition of irrelevant memory pictures having no connection with the important associations does not really occur. An exception not contrary to the rule may be postulated for those reminiscences which, though in themselves unimportant, are indispensable as intercalations, since the associations between two related reminiscences passed through them only.—As mentioned above, the period during which a reminiscence abides in the pass of the patient’s consciousness is directly proportionate to its significance. A picture which does not disappear requires further consideration; a thought which cannot be abolished must be followed further. A reminiscence never recurs if it has been adjusted, a picture spoken away cannot be seen again. However, if that does happen it can be definitely expected that the second time the picture will be joined by a new content of thought, that the idea will contain a new inference which will show that no perfect adjustment has taken place. On the other hand, a recurrence of different intensities, at first vaguely then quite plainly, often occurs, but it does not, however, contradict the assertion just advanced.
If the object of the analysis is to remove a symptom (pains, symptoms like vomiting, sensations and contractures) which is capable of aggravation or recurrence, the symptom shows during the work the interesting and not undesirable phenomenon of “joining in the discussion.” The symptom in question reappears, or appears with greater intensity, as soon as one penetrates into the region of the pathogenic organization containing the etiology of this symptom, and it continues to accompany the work with characteristic and instructive fluctuations. The intensity of the same (let us say of a nausea) increases the deeper one penetrates into its pathogenic reminiscence; it reaches its height shortly before the latter has been expressed, and suddenly subsides or disappears completely for a while after it has been fully expressed. If through resistance the patient delays the expression, the tension of the sensation of nausea becomes unbearable, and, if the expression cannot be forced, vomiting actually sets in. One thus gains a plastic impression of the fact that the vomiting takes the place of a psychic action (here that of speaking) just as was asserted in the conversion theory of hysteria.
The fluctuations of intensity on the part of the hysterical symptom recurs as often as one of its new and pathogenic reminiscences is attacked; the symptom remains, as it were, all the time the order of the day. If it is necessary to drop for a while the thread upon which this symptom hangs, the symptom, too, merges into obscurity in order to emerge again at a later period of the analysis. This play continues until, through the completion of the pathogenic material, there occurs a definite adjustment of this symptom.
Strictly speaking the hysterical symptom does not behave here differently than a memory picture or a reproduced thought which is evoked by the pressure of the hand. Here, as there, the adjustment necessitates the same obsessing obstinacy of recurrence in the memory of the patient. The difference lies only in the apparent spontaneous appearance of the hysterical symptom, whereas one readily recalls having himself provoked the scenes and ideas. But in reality the memory symbols run in an uninterrupted series from the unchanged memory remnants of affectful experiences and thinking-acts to the hysterical symptoms.
The phenomenon of “joining in the discussion” of the hysterical symptom during the analysis carries with it a practical inconvenience to which the patient should be reconciled. It is quite impossible to undertake the analysis of a symptom in one stretch or to divide the pauses in the work in such a manner as to precisely coincide with the resting point in the adjustment. Furthermore, the interruption which is categorically dictated by the accessory circumstances of the treatment, like the late hour, etc., often occurs in the most awkward locations, just when some critical point could be approached or when a new theme comes to light. These are the same inconveniences which every newspaper reader experiences in reading the daily fragments of his newspaper romance, when, immediately after the decisive speech of the heroine, or after the report of a shot, etc., he reads, “To be continued.” In our case the raked-up but unabolished theme, the at first strengthened but not yet explained symptom, remains in the patient’s psyche, and troubles him perhaps more than before.
But the patient must understand this as it cannot be differently arranged. Indeed, there are patients who during such an analysis are unable to get rid of the theme once touched; they are obsessed by it even during the interval between the two treatments, and as they are unable to advance alone with the adjustment, they suffer more than before. Such patients, too, finally learn to wait for the doctor, postponing all interest which they have in the adjustment of the pathogenic material for the hours of the treatment, and they then begin to feel freer during the intervals.
Usually the deeper one penetrates into the above described layers of the psychic structure the more obscure and difficult the work will at first become. But once the nucleus is reached light ensues, and there is no more fear that a marked gloom will be cast over the condition of the patient. However, the reward of the labor, the cessation of symptoms of the disease can only be expected when the full analysis of every individual symptom has been accomplished; indeed where the individual symptoms are connected through many junctures one is not even encouraged by partial successes during the work. By virtue of the great number of existing causal connections every unadjusted pathogenic idea acts as a motive for the complete creation of the neurosis, and only with the last word of the analysis does the whole picture of the disease disappear, just as happens in the behavior of the individual reproduced reminiscence.
If a pathogenic reminiscence or a pathogenic connection which was previously withdrawn from the ego-consciousness is revealed by the work of the analysis and inserted into the ego, one can observe in the psychic personality which was thus enriched the many ways in which it gave utterance to its gain. Especially does it frequently happen that after the patients have been painstakingly forced to a certain knowledge, they say: “Why I have known that all the time, I could have told you that before.” Those who have more insight recognize this afterwards as a self deception and accuse themselves of ungratefulness. In general the position that the ego takes towards the new acquisition depends upon the strata of the analysis from which the latter originates. Whatever belongs to the outermost layers is recognized without any difficulty, for it always remained in the possession of the ego, and the only thing that was new to the ego was its connection with the deeper layers of the pathogenic material. Whatever is brought to light from these deeper layers also finds appreciation and recognition, but frequently only after long hesitation and reflection. Of course, visual memory pictures are here more difficult to deny than reminiscences of mere streams of thought. Not very seldom the patient will at first say, “it is possible that I, thought of that, but I cannot recall it,” and only after a longer familiarity with this supposition recognition will appear. He then recalls and even verifies by sight associations that he once really had this thought. During the analysis I make it a point of holding the value of an emerging reminiscence independent of the patient’s recognition. I am not tired of repeating that we are obliged to accept everything that we bring to light with our means. Should there be anything unreal or incorrect in the material thus revealed, the connection will later teach us to separate it. I may add that I rarely ever have occasion to subsequently withdraw the recognition from a reminiscence which I had preliminarily admitted. In spite of the deceptive appearance of an urgent contradiction, whatever came to the surface finally proved itself correct.
Those ideas which originate in the deepest layer, and from the nucleus of the pathogenic organization, are only with the greatest difficulty recognized by the patient as reminiscences. Even after everything is accomplished, when the patients are overcome by the logical force and are convinced of the curative effect accompanying the emerging of this idea—I say even if the patients themselves assume that they have thought “so” and “so” they often add, “but to recall, that I have thought so, I cannot.” One readily comes to an understanding with them by saying that these were unconscious thoughts. But how should we note this state of affairs in our own psychological views? Should we pay no heed to the patient’s demurring recognition which has no motive after the work has been completed; should we assume that it was really a question of thoughts which never occurred, and for which there is only a possibility of existence so that the therapy would consist in the consummation of a psychic act which at that time never took place? It is obviously impossible to state anything about it, that is, to state anything concerning the condition of the pathogenic material previous to the analysis, before one has thoroughly explained his psychological views especially concerning the essence of consciousness. It is a fact worthy of reflection that in such analyses one can follow a stream of thought from the conscious into the unconscious (that is, absolutely not recognized as a reminiscence) thence draw it for some distance through the consciousness, and again see it end in the unconscious; and still this variation of the psychic elucidation would change nothing in it, in its logicalness, and in a single part of its connection. Should I then have this stream of thought freely before me, I could not conjecture what part was, and what part was not recognized by the patient as a reminiscence. In a measure I see only the points of the stream of thought merging into the unconscious, just the reverse of that which has been claimed for our normal psychic processes.
I have already alluded to the important rôle falling to the personality of the physician in the creation of motives which are to overcome the psychic force of the resistance. In not a few cases, especially in women and where we deal with the explanation of erotic streams of thought, the cooperation of the patient becomes a personal sacrifice which must be recompensed by some kind of a substitute of love. The great effort and the patient friendliness for the physician suffice as such substitutes. If this relation of the patient to the physician is disturbed the readiness of the patient fails; if the physician desires information concerning the next pathogenic idea, the patient is confronted by the consciousness of the unpleasantness which has accumulated in her against the physician. As far as I have discovered this obstacle occurs in three principal cases:
1. In personal estrangement, if the patient believes herself slighted, disparaged and insulted, or if she hears unfavorable accounts concerning the physician and his methods of treatment. This is the least serious case. The obstacle can readily be overcome by discussion and explanation, although the sensitiveness and the suspicion of hysterics can occasionally manifest itself in unsuspected dimensions.
2. If the patient is seized with the fear that she becomes too accustomed to her physician, that in his presence she loses her independence and could even become sexually dependent upon him; this case is more significant because it is less determined individually. The occasion for this obstacle lies in the nature of the therapeutic distress. The patient has now a new motive to resist which manifests itself, not only in a certain reminiscence but at each attempt of the treatment. Whenever the pressure procedure is started the patient usually complains of headache. Her new motive for the resistance remains to her for the most part unconscious, and she manifests it by a newly created hysterical symptom. The headache signifies the aversion towards being influenced.
3. If the patient fears lest the painful ideas emerging from the content of the analysis would be transferred to the physician. This happens frequently, and, indeed, in many analyses it is a regular occurrence. The transference to the physician occurs through false connections. I must here give an example. The origin of a certain hysterical symptom in one of my hysterical patients was the wish she entertained years ago which was immediately banished into the unconscious, that the man with whom she at that time conversed would heartily grasp her and force a kiss on her. After the ending of a session such a wish occurred to the patient in reference to me. She was horrified and spent a sleepless night, and at the next session, although she did not refuse the treatment she was totally unfit for the work. After I had discovered the obstacle and removed it, the work continued. The wish that so frightened the patient appeared as the next pathogenic reminiscence, that is, as the one now required by the logical connection. It came about in the following manner: The content of the wish at first appeared in the patient’s consciousness without the recollection of the accessory circumstances which would have transferred this wish into the past. By the associative force prevailing in consciousness the existing wish became connected with my own person, with which the patient could naturally occupy herself, and in this mesalliance—which I call a false connection—the same affect became reawakened which originally urged the patient to banish this clandestine wish. As soon as I discovered this I could presuppose every similar claim on my personality to be another transference and false connection. It is remarkable how the patient falls a victim to deception on every new occasion.
No analysis can be brought to an end if one does not know how to meet the resistances resulting from the causes mentioned. The way can be found if one bears in mind that the new symptom produced after the old model should be treated like the old symptoms. In the first place it is necessary to make the patient conscious of the obstacle. In one of my patients, in whom the pressure symptoms suddenly failed and I had cause to assume an unconscious idea like the one mentioned in 2, I met it for the first time with an unexpected attack. I told her that there must have originated some obstacle against the continuation of the treatment and that the pressure procedure has at least the power to show her the obstacle, and then pressed her head. She then said, surprisingly, “I see you sitting here on the chair, but that is nonsense, what can that mean?”—But now I could explain it.
In another patient the obstacle did not usually show itself directly on pressure, but I could always demonstrate it by taking the patient back to the moment in which it originated. The pressure procedure never failed to bring back this moment. By discovering and demonstrating the obstacle, the first difficulty was removed, but a greater one still remained. The difficulty lay in inducing the patient to give information where there was an obvious personal relation and where the third person coincided with the physician. At first I was very much annoyed about the increase of this psychic work until I had learned to see the lawful part of this whole process, and I then also noticed that such a transference does not cause any considerable increase in the work. The work of the patient remained the same, she perhaps had to overcome the painful affect of having entertained such a wish, and it seemed to be the same for the success whether she took this psychic repulsion as a theme of the work in the historical case or in the recent case with me. The patients also gradually learned to see that in such transferences to the person of the physician they generally dealt with a force or a deception which disappeared when the analysis was accomplished. I believe, however, that if I should have delayed in making clear to them the nature of the obstacle, I would have given them a new, though a milder, hysterical symptom for another spontaneously developed.
When I promised my patients help and relief through the cathartic method, I was often obliged to hear the following objections: “You say, yourself, that my suffering has probably to do with my own relation and destinies. You cannot change any of that. In what manner, then, can you help me?” To this I could always answer: “I do not doubt at all that it would be easier for destiny than for me to remove your sufferings, but you will be convinced that much will be gained if we succeed in transforming your hysterical misery into everyday unhappiness, against which you will be better able to defend yourself with a restored nervous system.”