THE PSYCHOTHERAPY OF HYSTERIA.
In our “Preliminary Communication” we have stated that while
investigating the etiology of hysterical symptoms we have also
discovered a therapeutic method which we consider of practical
significance. “We found, at first to our very greatest surprise, that
the individual hysterical symptoms immediately disappeared without
returning if we succeeded in thoroughly awakening the memories of the
causal process with its accompanying affect, and if the patient
circumstantially discussed the process giving free play to the affect”
(p. 4).
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.
I.
I, for my part, may state that I can adhere to the “Preliminary
Communication,” but I must confess that after continuous occupation for
years with the problems therein touched, I was confronted with new
views, as a result of which the former material underwent at least a
partial change in grouping and conception. It would be unjust to impute
too much of the responsibility for this development to my honored
friend, J. Breuer. I therefore take the weight of responsibility upon
myself.
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 plan 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[27]
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 be 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.,[28] 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,[29] 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 over-determined, 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.[30]
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 shall now mention those difficulties and inconveniences of our
therapeutic method which are not evident from the preceding histories,
or from the following remarks concerning the technique of the method.—I
will rather enumerate and indicate than carry them out. The process is
toilsome and wearisome for the physician, it presupposes a profound
interest for psychological incidents, as well as a personal sympathy for
the patient. I could not conceive myself entering deeply into the
psychic mechanism of a hysteria in a person who appeared to me common
and disagreeable, and who would not, on closer acquaintanceship, be able
to awaken in me human sympathy; whereas I can well treat a tabetic or a
rheumatic patient regardless of such personal liking. Not less are the
requisites on the patient’s side. The process is especially inapplicable
below a certain niveau of intelligence. It is rendered extremely
difficult wherever there is any tinge of weakmindedness. It requires the
full consent and the attention of the patients, but, above all, their
confidence, for the analysis regularly leads to the inmost and most
secretly guarded psychic processes. A large proportion of the patients
suitable for such treatment withdraw from the physician as soon as they
become cognizant whither his investigations tend; to them the physician
remains a stranger. In others who have determined to give themselves up
to the physician and bestow their confidence upon him, something usually
voluntarily given but never demanded, in all those, I say, it is hardly
avoidable that the personal relation to the physician should not become
unduly prominent, at least for some time. Indeed, it seems as if such an
influence exerted by the physician is a condition under which alone a
solution of the problem is made possible. I do not believe that it makes
any essential difference in this condition whether we make use of
hypnosis or have to avoid or substitute it. Yet fairness demands that we
emphasize the fact that although these inconveniences are inseparable
from our method, they, nevertheless, cannot be charged to it. It is much
more evident that they are formed in the preliminary states of the
neurosis to be cured, and that they then attach themselves to every
medical activity which intensively concerns itself with the patient, and
produce in him a psychic change. I could see no harm or danger in the
application of hypnosis even in those cases where it was used
excessively. The causes for the harm produced lay elsewhere and deeper.
When I review the therapeutic efforts of those years since the
communications of my honored teacher and friend, J. Breuer, gave me the
cathartic method, I believe that I have more often produced good than
harm, and brought about some things which could not have been produced
by any other therapeutic means. On the whole it was, as expressed in the
“Preliminary Communication,” “a distinct therapeutic gain.”
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.
II.
I will now add to my former observations that in attempting to use
Breuer’s method in greater latitude I met this difficulty—although the
diagnosis was hysteria, and the probabilities spoke in favor of the
prevalence of the psychic mechanism described by us, yet a number of
patients could not be put into the hypnotic state. The hypnosis was
necessary to broaden consciousness so as to find the pathogenic
reminiscences which do not exist in the ordinary consciousness. I,
therefore, was forced to either give up such patients, or to bring about
this broadening by other means.
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. This 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 forms 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[31] 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 reinforced 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.
Some time ago I attempted to relieve an elderly lady of her anxiety
attacks, which considering their characteristic qualities, were hardly
adapted to such influence. Since her menopause she had become extremely
religious, and always received me as if I were the Devil. She was always
armed with a small ivory crucifix which she hid in her hand. Her attacks
of anxiety, which bore the hysterical character, could be traced to her
early girlhood, and were supposed to have originated from the
application of an iodine preparation used to reduce a moderate swelling
of the thyroid. I naturally repudiated this origin, and sought to
substitute it by another which was in better harmony with my views
concerning the etiology of neurotic symptoms. To the first question for
an impression of her youth which would stand in causal connection to the
attacks of anxiety, there appeared under the pressure of my hand the
reminiscence of reading a so called devotional book wherein piously
enough there was some mention of the sexual processes. The passage in
question made an impression on this girl, which was contrary to the
intention of the author. She burst into tears and flung the book away.
That was before the first attack of anxiety. A second pressure on the
forehead of the patient evoked the next reminiscence, it referred to her
brother’s teacher who showed her great respect, and for whom she
entertained a warmer feeling. This reminiscence culminated in the
reproduction of an evening in her parents’ home, during which they all
sat around the table with the young man, and delightfully enjoyed
themselves in a lively conversation. During the night following this
evening she was awakened by the first attack of anxiety which surely had
more to do with some resistance against a sensual feeling than perhaps
with the coincidently used iodine. In what other way could I have
succeeded in revealing in this obstinate patient, prejudiced against me
and every worldly remedy, such a connection contrary to her own opinion
and assertion?
On another occasion I had to deal with a young happily married woman,
who as early as in the first years of her girlhood, was found every
morning for some time in a state of lethargy, with rigid members, opened
mouth, and protruding tongue. Similar attacks, though not so marked,
recurred at the present time on awakening. A deep hypnosis could not be
produced, so that I began my investigation in a state of concentration,
and assured her during the first pressure that she would see something
that would be directly connected with the cause of her condition during
her childhood. She acted calmly and willingly, she again saw the
residence in which she had passed her early girlhood, her room, the
position of her bed, the grandmother who lived with them at the time,
and one of her governesses whom she dearly loved. There was then a
succession of small, quite indifferent scenes, in these rooms, and among
these persons, the conclusion of which was the leave taking of the
governess who married from the home. I did not know what to start with
these reminiscences; I could not bring about any connection between them
and the etiology of the attacks. To be sure the various circumstances
were recognized as having occurred at the same time at which the attacks
first appeared.
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 governess 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 governess 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.
Occasionally the explanations, which one obtains by the pressure
procedure, follow in very remarkable form, and under circumstances which
make the assumption of an unconscious intelligence appear even more
alluring. Thus I recall a lady who suffered for years from obsessions
and phobias, and who referred the origin of her trouble to her
childhood, but could mention nothing to which it could have been
attributed. She was frank and intelligent, and evinced only a very
slight conscious resistance. I will add here that the psychic mechanism
of obsessions is very closely related to that of hysterical symptoms,
and that the technique of the analysis in both is the same.
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 this 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 have thus far so warmly praised the achievements of the pressure
procedure, and have so entirely neglected the aspect of the defense or
the resistance, that I certainly must have given the impression that by
means of this small artifice one is placed in position to become master
of the psychic resistances against the cathartic cure. But to believe
this would be a gross mistake. Such advantages do not exist in the
treatment so far as I can see; here, as everywhere else, great change
requires much effort. The pressure procedure is nothing but a trick
serving to surprise for awhile the defensive ego, which in all graver
cases recalls its intentions and continues its resistance.
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 non appearance 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.
III.
In view of the discussions in the preceding section concerning the
difficulty of my technique, which I have unreservedly exposed,—I have
really collected them from my most difficult cases, though it will often
be easier work—in view then of this state of affairs everybody will wish
to ask whether it would not be more suitable, instead of all these
tortures, to apply oneself more energetically to hypnosis, or to limit
the application of the cathartic method to only such cases as can be
placed in deep hypnosis. To the latter proposition I should have to
answer that the number of patients available for my skill would shrink
considerably; but to the former advice I will advance the supposition
that even where hypnosis could be produced the resistance would not be
very much lessened. My experiences in this respect are not particularly
extensive, so that I am unable to go beyond this supposition, but
wherever I achieved a cathartic cure in the hypnotic state I found that
the work devolved upon me was not less than in the state of
concentration. I have only recently finished such a treatment during
which course I caused the disappearance of a hysterical paralysis of the
legs. The patient merged into a state, psychically very different from
the conscious, and somatically distinguished by the fact that she was
unable to open her eyes or rise without my ordering her to do so; and
still I never had a case showing greater resistance than this one. I
placed no value on these physical signs, and toward the end of the ten
months’ treatment they really became imperceptible. The condition of the
patient during our work has therefore lost nothing of its psychic
peculiarities, such as the ability to recall the unconscious and its
very peculiar relation to the person of the physician. To be sure, in
the history of Mrs. Emmy v. N. I have described an example of a
cathartic cure accomplished in a profound somnambulism in which the
resistance played almost no part. But nothing that I obtained from this
woman would have required any special effort; I obtained nothing that
she could not have told me in her waking state after a longer
acquaintanceship and some esteem. The real causes of her disease, which
were surely identical with the causes of her relapses after my
treatment, I have never found—it was my first attempt in this
therapy—and when I once asked her accidentally for a reminiscence which
contained a fragment of the erotic, I found her just as resistant and
unreliable in her statements as any one of my later non-somnambulic
patients. This patient’s resistance, even in the somnambulic state,
against other requirements and exactions I have already discussed in her
history. Since I have witnessed cases who, even in deep somnambulism
were absolutely refractory therapeutically despite their obedience in
everything else, I really became skeptical as to the value of hypnosis
for the facilitation of the cathartic treatment. A case of this kind I
have reported in brief,[32] and could still add others.
In our discussion thus far, the idea of resistance has thrust itself to
the foreground. I have shown how, in the therapeutic work, one is led to
the conception that hysteria originates through the repression of an
unbearable idea from a motive of defense, that the repressed idea
remains as a weak (mildly intensive) reminiscence, and that the affect
snatched from it is used for a somatic innervation, that is, conversion
of the excitement. By virtue of its repression the idea becomes the
cause of morbid symptoms, that is pathogenic. A hysteria showing this
psychic mechanism may be designated by the name of “defense hysteria,”
but both Breuer and myself have repeatedly spoken of two other kinds of
hysterias which we have named hypnoid and retention hysteria. The first
to reveal itself to us was really the hypnoid-hysteria, for which I can
mention no better example than Breuer’s case of Miss Anna O.[33] For
this form of hysteria Breuer gives an essentially different psychic
mechanism than for the form which is characterized by conversion. Here
the idea becomes pathogenic through the fact that it is conceived in a
peculiar psychic state, having remained from the very beginning external
to the ego. It therefore needs no psychic force to keep it away from the
ego, and it need not awaken any resistance when, with the help of the
somnambulic psychic authority, it is initiated into the ego. The history
of Anna O. really shows no such resistance.
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.
Thus far I have dealt with the difficulties and technique of the
cathartic method, I would now like to add a few indications showing how
one makes an analysis with technique. For me this is a very interesting
theme, but I do not expect that it will excite similar interest in
others who have not practiced such analyses. Properly speaking we shall
again deal with the technique, but this time with those difficulties
concerning which the patient cannot be held responsible, and which must
in part be the same in a hypnoid and a retention hysteria as well as in
the defense hysteria which I have in mind as a model. I start on this
last fragment of discussion with the expectation that the psychic
peculiarities revealed here might sometime attain a certain value as raw
material for an intellectual dynamics.
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 arrangements in
Breuer’s analysis of Anna O. The theme is that of becoming deaf, of not
hearing,[34] 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 sub-divisions; 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 spacially 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 recompose 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 strata, 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 strata 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 strata, 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 strata.
The threads are dropped, taken up again, and followed up 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 fluctuation 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 awhile 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.
The general condition of the patient during such an analysis seems also
worthy of consideration. For a while it remains uninfluenced by the
treatment expressing the former effective factors. But then a moment
comes in which the patient is seized, and his interest chained and from
that time his general condition becomes more and more dependent on the
condition of the work. Whenever a new explanation is gained and an
important contribution in the chain of the analysis is reached, the
patient feels relieved and experiences a presentiment of the approaching
deliverance; but at each standstill of the work, at each threatening
entanglement, the psychic burden which oppresses him grows, and the
unhappy sensation of his incapacity increases. To be sure, both
conditions are only temporary, for the analysis continues disdaining to
boast of a moment of wellbeing, and continues regardlessly over the
period of gloominess. One is generally pleased if it is possible to
substitute the spontaneous fluctuations in the condition of the patient
by such as one himself provokes and understands, just as one prefers to
see in place of the spontaneous discharge of the symptoms that order of
the day which corresponds to the condition of the analysis.
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 the 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
gives 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 still have another theme to treat which plays an undesirably great
part in the work of such a cathartic analysis. I have already admitted
the possibility that the pressure procedure may fail and despite all
assurance and urging it may evoke no reminiscences. I also stated that
two possibilities are to be considered, there is really nothing to evoke
in the place where we investigate—that can be recognized by the
perfectly calm expression of the patient—or, we have struck against a
resistance to be overcome only at some future time. We are confronted
with a new layer into which we cannot as yet penetrate, and this can
again be read from the drawn and psychic exertion of the patient’s
expression. A third cause may be possible which also indicates an
obstacle, not as to the purport, but externally. This cause occurs when
the relation of the patient to the physician is disturbed, and signifies
the worst obstacle that can be encountered. One may consider that in
every more serious analysis.
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.[35]
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.
I now believe that I have sufficiently indicated how such analyses
should be executed, and the experiences connected with them. They
perhaps make some things appear more complicated than they are, for many
things really result by themselves during such work. I have not
enumerated the difficulties of the work in order to give the impression
that in view of such requirements it pays for the physician and patient
to undertake a cathartic analysis only in the rarest cases. I allow my
medical activities to be inflected by the contrary suppositions.—To be
sure I am unable to formulate the most definite indications for the
application of the here discussed therapeutic method without entering
into the valuation of the more significant and more comprehensive theme
of the therapy of the neuroses in general. I have often compared the
cathartic psychotherapy to surgical measures, and designated my cures as
psychotherapeutic operations; the analogies follow the opening of a pus
pocket, the curetting of a carious location, etc. Such an analogy finds
its justification, not so much in the removal of the morbid as in the
production of better curative conditions for the issue of the process.
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.”