Y. B., born 1883, a law clerk. Patient comes on the third of December,
1908, to Frank's consultation hour; he complains of periods of short breath;
during these he feels as if his heart were ceasing to beat, especially when
he is just going to bed. He feels then as if something heavy were striking
him on the chest, great restlessness, and a feeling of faintness comes over
him. After taking a glass of wine the condition is aggravated and becomes
insupportable. These attacks come once or twice a day, mostly in the
evenings. At times they keep off for eight or ten days. He lives
continually in an excited state, he suffers from palpitations of the heart,
from pain in the left thigh, pain in the left side, and at night cannot get
to sleep.
Patient attributes this condition to an automobile accident which happened
to him on June 2, 1908. Even before this accident he had been a trifle
nervous on account of overwork. In the automobile accident he had been
thrown out, and had been thrown a distance of ten or fifteen yards. The
automobile, which was at high speed, had also plunged down the decline, but
luckily the patient was not caught directly under the machine. He did not
lose consciousness, and escaped with some scratches and a bad fright; it was
a marvel that he and the chauffeur escaped with their lives. He plainly
recalls thinking, during the fall, that his last hour had come, and even yet
is amazed how extremely untroubled he had been by that thought. The days
following the accident he felt as if his face were burning, and he was
inwardly agitated whenever he thought of an automobile. On June 30, 1908, he
was obliged to take a business journey. While seated in the station
restaurant it suddenly grew dark before his eyes. He could breathe only with
difficulty, his heartbeats were irregular and he had a strange sensation of
fear. This condition lasted the whole day. On the return journey his train
ran into an automobile truck. The patient was thrown to the floor of the
coupe by the shock. This incident made a great impression upon him;
nevertheless, for eight days he was free from the uneasiness already
described. After that an attack of fear again set in, continuing at
intervals, with periods of greater or lesser violence, until the present.
December 7, 1908. A first attempt to induce hypnosis was successful.
December 8, 1908. Patient goes to sleep immediately, becomes frightened and
gives frequent signs of terror. When awakened, he mentioned that he had had
a feeling as if he were falling into a hole, that had given him a very
strange sensation. The patient speaks while he sleeps; his
super-consciousness therefore remains awake and is able to take notice
directly of the scene taking place. After some minutes he sees in the
hypnosis a locomotive approaching. He cries out, "There it comes out of the
tunnel." He is afraid of being run over, and is terrified. Two years
previously he had been through this scene. He was standing on the track when
a train approached, and he was afraid of being run over. In his sleep, the
patient communicates the details and sees everything clearly. After a short
interval of complete rest, he begins to breathe heavily, his pulse quickens,
then he cries out in fright and excitement and dread, "Now it's coming, now
the auto's coming, it's turning over, we're under it, there it's riding over
us!" Gradually he quiets down again, and after a quarter of an hour, awakes.
He says he now feels something lifted from his chest, that he has slept
well, and feels better. He recalls everything. The train came out of the
tunnel with gleaming lights; this scene took place in the evening. The
automobile scene was reproduced precisely as he had taken part in it, no
detail escaped him; his breathing is unobstructed now, and he has no more
heart palpitations.
On the day appointed for the seance I was unexpectedly obliged to go away.
When I wished to resume the treatment, January 9, the patient wrote me that
his condition was strikingly improved, the heart palpitations and feelings
of anxiety had not reappeared. His pleasure in life and work had returned
once more, his night's rest left nothing to be desired, his appetite was
excellent, therefore he thought that further treatment was not necessary for
the present. To a later inquiry, February 12, 1910, a year afterwards, I
obtained this answer: "Without exaggeration I am able to write you that in
my whole life I have never felt so well as now. There has been no question
of any nervous attacks or feelings of dread. My weight, which had gone down
to fifty-eight kilos during my nervous sickness, has gone up to seventy
kilos."
When Frank shuts himself up with his patients in a room, from which all
outer noises are excluded as much as possible, by means of double windows
and doors, although he--by means of electric light signals visible to him
alone--keeps in touch with the servant outside, he has the patient recline
as comfortably as possible upon a low sofa. He kneels on a cushion at the
head, bends down over the patient and has the latter look upwards directly
into his eyes. Meanwhile he lets his left hand rest upon the patient's
forehead and gently presses the latter's eyelids with his thumb and
forefinger. As soon as the patient shows signs of weariness, he carefully
gets up, takes a seat next to the patient and continues carefully observant
of the latter's behavior and expression of countenance. He makes note of
everything that shows itself and rouses the patient after about a quarter of
an hour, unless the latter awakes spontaneously. Now he talks over with him
the material which has been procured and then has the patient go into a
renewed hypnosis, until the end of an hour. Sometimes the seances are
protracted when important scenes come up, and in the interest of the
treatment it might be lengthened to two or even three hours.
Bezzola makes use of a small, light, black silk mask, which he puts on the
eyes of the patient. He induces hypnosis, and for the rest follows Frank's
technique already described.
While analysts who avail themselves of hypnosis as a means of help have all
their patients take a reclining position, those who have given up hypnotism
in their treatment, have also given up this reclining position. Freud
continues to prefer having the patient assume a reclining position, and
takes his position with his back to the patient, behind the head of the
sofa. He considers that this manner of treatment induces the greatest
calmness in the patient and makes it easier for him to express himself and
to confess. He keeps as quiet as possible, listens with undivided attention,
does not take any notes during the seance, not wishing to give rise to the
suspicion that all the confession will be written down and perhaps seen by
other eyes.
Jung receives the patient in his study just as he would receive any ordinary
visitor. He thinks that in this way the patient is put most at his ease and
that it makes him feel he is not considered as a patient, but rather as some
one who, being in difficulties, comes to ask advice and needs to tell his
troubles to a trusted friend. Even less than Freud does he take notes in the
presence of the patient.
Stekel does as Jung, the only difference being that he remains seated at his
writing-table and makes notes of the most important points.
The most satisfactory way for the uninitiated to make himself familiar with
the technique of psychoanalysis is to submit himself to psychoanalysis. For
that purpose one turns to an experienced analyst, and takes to him one's
ideas and dreams. Consequently I submitted myself for two months to
analysis from Dr. Jung, who in that way initiated me into the practice of
psychological investigation. The interpretation of one's own dreams,
reading and studying of the principal literature about analytical psychology
or deep psychology, as Bleuler calls it; and the application of what is thus
learned, at the start to simple, later to more difficult cases, must do the
rest in making an independent investigator in this branch of psycho-therapy.
As has already been said, psychoanalysis aims at bringing into consciousness
all the forgotten things. When all the gaps in the memory are filled in,
when all the puzzling operations of the psychological life are explained,
then the continuance and the return of the suffering has become impossible.
The attainment of this ideal state is truly the attainment of Utopia. Most
certainly a treatment does not need to be carried so far. One may be
satisfied with the practical cure of the patient, with the restoration of
his power for work, and with the abolition of the most difficult functional
disturbances.
It is applicable in cases of chronic psychoneurosis which exhibit no
difficult or dangerous phenomena. Among these are counted all sorts of
compulsive neuroses, compulsive thoughts, compulsive behavior and cases of
hysteria, where phobias and obsessions play a chief role, also somatic
phenomena of hysteria which do not need to be acted upon quickly, such as,
for example, anorexia. In acute cases of hysteria it is better to wait for
a calmer period before applying psychoanalysis. In cases of nervous
prostration this manner of treatment, which demands the serious co-operation
and attention of the patient, which lasts a long time and at first takes no
notice of the continuance of the phenomena, is difficult. This form of
psychotherapy places great demands on the physician's patience and
understanding. Psychoanalyses which last more than a year, are no rarity. It
cannot be applied to the seriously degenerated; to people who have passed
far beyond middle life, because among the last named the accumulated
material compasses too much; to those who are entangled in a state of great
fear and who live in deep depression. Analysis can be applied to the
neuroses of children. It is desirable in those cases for the physician to
be supported by a trusted person, as for example a woman assistant, but
preferably by parents enlightened sufficiently to observe the spontaneous
remarks of the child, to make notes of them, and communicate them to the
physician. According to the experiments undertaken by the Zurich school, the
expectation is justified within certain limits, that psychoanalysis will be
therapeutically useful in certain forms of paranoia and dementia praecox.
I think that it will soon be said of psychoanalysis, as of so many other
systems which like it were decried and yet later were highly valued, that
the enemies of to-day are the friends of to-morrow.
Whoever wishes to judge Freud must take the trouble to initiate himself
seriously into his doctrines, and use his methods for a long time in
practice, according to his instructions.
Most of the condemnations are brought forward by investigators who judge a
priori, without acquaintance with the facts, upon uncertain theoretical
grounds and with prepossession against his sexual theory.
Whoever initiates himself seriously into the practice of psychoanalysis,
will arrive at the conclusion that this new form of psychical curing
deserves, to a great degree, the attention of the physician and that it may
be considered as an enrichment of the armory of the psychotherapy, not yet
sufficiently valued.
Does it render other forms of psychotherapy superfluous? There can be no
thought of that.
Taking the pros and cons given here, we see that each of the forms of
psychical therapy deserves in its turn preference, and that all support and
complement each other.
Jung, as well as Freud, both of whom have made their life's aim the
perfection of psychoanalysis, and who for that reason now concern themselves
exclusively with it, appreciate all forms of verbal treatment, as well with
hypnotism as without it. Hypnotic suggestion and suggestion given when awake
was used at an earlier period by both of them with good results, and they
still are not averse to using this method where quick comprehension and the
immediate subdual of a troublesome symptom is desired.
The psychoanalyst follows the longer road, and assails rather the root of
the sickness; it works more radically; hypnotic treatment takes hold quicker
and is directed at the symptoms.
Freud explains it in this manner: when one treats the patient by hypnotic
suggestion, one introduces a new idea from outside in exchange for the
morbid idea; if psychoanalysis is applied, then one simply eliminates the
morbid idea. Within certain limits the modus agendi of the two methods is in
absolute opposition.
The suggestion method, substituting one idea for another, puts in something;
the analytical, expelling an idea, takes out something. Both aim at and
obtain the same end, a more or less lasting cure. Suggestion neutralizes,
stops the poison; analysis expels the harmful matter. The latter manner of
treatment is positive and the most decisive.
"Don't we all analyze?" Bernheim inquires, and once more I agree that all
forms of psychotherapeutics do, but there is a difference in analysis.
Superficial analysis can bring us a long way toward the goal. In many cases
it may suffice. But the profound, the Freudian analysis, is what we need if
we wish to attain the radical cure of psychoneurosis, as far as we can ever
speak of a radical cure. Many cases of illness do not lend themselves to
deep analysis.
When, because of the nature of the illness, or the lifetime, or the feeble
intelligence of the patient, or because of temporary circumstances of a
moral or material nature, its adaptation is excluded or impossible, it is
advisable, especially in chronic cases-- to take refuge in the more
palliative forms of the psychic methods of cure.
Thus the psychotherapeutic as moral leader fills the role of guide
(directeur-d'ames), one who helps along the doubter, encourages the toilers,
calms the frightened, arouses courage, keeps up hope and comforts where
comfort is needed.
Pierre Janet, in his instructive book ("Obsessions et Idees Fixes"),
observes that one of his chronic patients gave him the pet name of "le
remonteur de pendules," an expression which luminously describes the role of
the physician of souls, who, tirelessly, day in, day out, lifts the burdens,
and for a time breathes new life into the depressed.
Hypnotic suggestion, which induces sleep, stills pain, silences fear,
abolishes functional disturbances, works chiefly palliatively. The place for
its application is where quick comprehension is desired. In its simplest
form it resembles the treatment of a mother, who soothes her child with
pacifying words and loving touch, and rocks him to sleep, and also it
resembles the behavior of the father, who asserts his authority by force and
breaks down the childish opposition. We find hypnotic suggestion, perfected
and clothed in its scientific garment, in Liebeault's assertion: "It is a
cure of authority, of faith, of confidence, a cure which frequently performs
semi-miracles. Respect on one side, sympathy on the other, is what gives the
hypnotiser results."
However highly we may value this last mentioned form of therapy, however
numerous the cures due to it may be, however indispensable it may be in the
practice of medicine, yet its splendor pales before the light which shines
forth from the cures which aim at reeducation and which are directed toward
the understanding. Those are the cures which make use of analysis.
One method, which we will call the superficial analytical method, is
directed exclusively toward the upper consciousness and cures principally
through exhorting, convincing, exercising and hardening. Its sponsors are
Bernheim, Rosenbach, P. E. Levy, Dubois. At least it is true to its birth,
it has suggestion blood in its veins.
The other method is the deeper: the Freudian analysis. This does not allow
itself to be satisfied with seeing only one side of the medal, it does not
limit its field of activity to the superliminal consciousness, in searching
for the causes of psychogenic illnesses, but it penetrates into the strata
which lie hidden under the threshold of the consciousness.
Where the moral and the suggestive methods of cure are limited exclusively
to symptomatic treatment, the first form of educative therapy, limited
merely to a superficial analysis, is only partly symptomatic, but the second
form of educative therapy penetrates with its deep-going analysis to the
root of the trouble, and has as its aim a fundamental cure.
Only too frequently the physician must be satisfied with the cure of the
symptoms, with lightening the load. He always strives to remove the cause.
Freud's great service is that he has opened before the physician a path
which leads to the cause.
These lines of Vondel's seem as if composed for him:
"The physician must not only know How high the pulse has mounted, And
where the sickness lies, which makes him groan with pain, But he must see
the cause, from where The great weakness of this sickness came."