I must supplement what I have just said by explaining that from the very
first I made use of hypnosis in another manner, apart from hypnotic
suggestion. I used it for questioning the patient upon the origin of his
symptom, which in his waking state he could often describe only very
imperfectly or not at all. Not only did this method seem more effective
than bald suggestive commands or prohibitions, but it also satisfied the
curiosity of the physician, who, after all, had a right to learn
something of the origin of the phenomenon which he strove to remove by
the monotonous procedure of suggestion.
The manner in which I arrived at this other procedure was as follows:
While I was still working in Brücke’s laboratory I had made the
acquaintance of Dr. Josef Breuer, who was one of the most respected
family physicians in Vienna, but who also had a scientific past, since
he had produced several works of permanent value upon the physiology of
breathing and upon the organ of equilibrium. He was a man of striking
intelligence and fourteen years older than myself. Our relations soon
became more intimate and he became my friend and helper in my difficult
circumstances. We grew accustomed to share all our scientific interests
with each other. In this relationship the gain was naturally mine. The
development of psychoanalysis afterwards cost me his friendship. It was
not easy for me to pay such a price, but I could not escape it.
Even before I went to Paris, Breuer had told me about a case of hysteria
which, between 1880 and 1882, he had treated in a peculiar manner which
had allowed him to penetrate deeply into the causation and significance
of hysterical symptoms. This was at a time, therefore, when Janet’s
works still belonged to the future. He repeatedly read me pieces of the
case history, and I had an impression that it accomplished more towards
an understanding of neuroses than any previous observation. I determined
to inform Charcot of these discoveries when I reached Paris, and I
actually did so. But the great man showed no interest in my first
outline of the subject, so that I never recurred to it and allowed it to
pass from my mind.
When I was back in Vienna I turned once more to Breuer’s observation and
made him tell me more about it. The patient had been a young girl of
unusual education and gifts, who had fallen ill while she was nursing
her father, of whom she was devotedly fond. When Breuer took over her
case it presented a variegated picture of paralyses and contractures,
inhibitions and states of mental confusion. A chance observation showed
her physician that she could be relieved of these clouded states of
consciousness if she was induced to express in words the affective
phantasy by which she was at the moment dominated. From this discovery,
Breuer arrived at a new method of treatment. He put her into deep
hypnosis and made her tell him each time what it was that was oppressing
her mind. After the attacks of depressive confusion had been overcome in
this way, he employed the same procedure for removing her inhibitions
and physical disorders. In her waking state the girl could no more
describe than other patients how her symptoms had arisen, and she could
discover no link between them and any experiences of her life. In
hypnosis she immediately revealed the missing connection. It turned out
that all of her symptoms went back to moving events which she had
experienced while nursing her father; that is to say, her symptoms had a
meaning and were residues or reminiscences of those emotional
situations. It turned out in most instances that there had been some
thought or impulse which she had had to suppress while she was by her
father’s sick-bed, and that, in place of it, as a substitute for it, the
symptom had afterwards appeared. But as a rule the symptom was not the
precipitate of a single such “traumatic” scene, but the result of a
summation of a number of similar situations. When the patient recalled a
situation of this kind in a hallucinatory way under hypnosis and carried
through to its conclusion, with a free expression of emotion, the mental
act which she had originally suppressed, the symptom was wiped away and
did not return. By this procedure Breuer succeeded, after long and
painful efforts, in relieving his patient of all her symptoms.
The patient had recovered and had remained well and, in fact, had become
capable of doing serious work. But over the final stage of this hypnotic
treatment there rested a veil of obscurity, which Breuer never raised
for me; and I could not understand why he had so long kept secret what
seemed to me an invaluable discovery instead of making science the
richer by it. The immediate question, however, was whether it was
possible to generalize from what he had found in a single case. The
state of things which he had discovered seemed to me to be of so
fundamental a nature that I could not believe it could fail to be
present in any case of hysteria if it had been proved to occur in a
single one. But the question could only be decided by experience. I
therefore began to repeat Breuer’s investigations with my own patients
and eventually, especially after my visit to Bernheim in 1889 had taught
me the limitations of hypnotic suggestion, I worked at nothing else.
After observing for several years that his findings were invariably
confirmed in every case of hysteria that was accessible to such
treatment, and after having accumulated a considerable amount of
material in the shape of observations analogous to his, I proposed to
him that we should issue a joint publication. At first he objected
vehemently, but in the end he gave way, especially since, in the
meantime, Janet’s works had anticipated some of his results, such as the
tracing back of hysterical symptoms to events in the patient’s life, and
their removal by means of hypnotic reproduction _in statu nascendi_. In
1893 we issued a preliminary paper, “On the Psychical Mechanism of
Hysterical Phenomena,”[8] and in 1895 there followed our book, _Studien
über Hysterie_.
If the account I have so far given has led the reader to expect that the
_Studien über Hysterie_ must, in all essentials of their material
content, be the product of Breuer’s mind, that is precisely what I
myself have always maintained and what it has been my aim to repeat
here. As regards the theory put forward in the book, I was partly
responsible, but to an extent which it is today no longer possible to
determine. That theory was in any case unpretentious and hardly went
beyond the direct description of the observations. It did not seek to
establish the nature of hysteria but merely to throw light upon the
origin of its symptoms. Thus it laid stress upon the significance of the
life of the emotions and upon the importance of distinguishing between
mental acts which are unconscious and those which are conscious (or
rather capable of being conscious); it introduced a dynamic factor, by
supposing that a symptom arises through the damming-up of an effect, and
an economic factor, by regarding that same symptom as the product or
equivalent of a quantity of energy which would otherwise have been
employed in some other way. (This latter process was described as
_conversion_.) Breuer spoke of our method as _cathartic_; its
therapeutic aim was explained as being to provide that the accumulated
affect used for maintaining the symptom, which had got onto the wrong
lines and had, as it were, become stuck there, should be directed onto
the normal path along which it could obtain discharge (or _abreaction_).
The practical results of the cathartic procedure were excellent. Its
defects, which became evident later, were those of all forms of hypnotic
treatment. There are still a number of psychotherapists who have not
gone beyond catharsis as Breuer understood it and who still speak in its
favor. Its value as an abridged method of treatment was shown afresh in
the hands of E. Simmel in the treatment of war neuroses in the German
army during the Great War. The theory of catharsis had not much to say
on the subject of sexuality. In the case histories which I contributed
to the _Studien_, sexual factors played a certain part, but scarcely
more attention was paid to them than to other emotional excitations.
Breuer wrote of the girl, who has since become famous as his first
patient, that her sexual side was extraordinarily undeveloped. It would
have been difficult to guess from the _Studien über Hysterie_ what an
importance sexuality has in the ætiology of the neuroses.
The stage of development which now followed, the transition from
catharsis to psychoanalysis proper, has been described by me several
times already in such detail that I shall find it difficult to bring
forward any new facts. The event which formed the opening of this period
was Breuer’s retirement from our common work, so that I became sole
administrator of his legacy. There had been differences of opinion
between us at quite an early stage, but they had not been a ground for
our separating. In answering the question of when it is that a mental
process becomes pathogenic, that is, when it is that it becomes
impossible for it to find a normal discharge, Breuer preferred what
might be called a physiological theory: he thought that the processes
which could not find normal outcome were such as had originated during
unusual, hypnoid, mental states. This opened the further question of the
origin of these hypnoid states. I, on the other hand, was inclined to
suspect the existence of an interplay of forces and the operation of
intentions and purposes such as are to be observed in normal life. Thus
it was a case of “Hypnoid Hysteria” versus “Defence Neurosis.” But such
differences as this would scarcely have alienated him from the subject
if there had not been other factors at work. One of these was
undoubtedly that his work as a physician and family doctor took up much
of his time and that he could not, like me, devote his whole strength to
the work of catharsis. Again, he was affected by the reception which our
book had received both in Vienna and in Germany. His self-confidence and
powers of resistance were not developed so fully as the rest of his
mental organization. When, for instance, the _Studien_ met with a severe
rebuff from Strümpell, I was able to laugh at the lack of comprehension
which his criticism showed, but Breuer felt hurt and grew discouraged.
But what contributed chiefly to his decision was that my own further
work led in a direction with which he found it impossible to reconcile
himself.
The theory which we had attempted to construct in the _Studien_
remained, as I have said, very incomplete; and in particular we had
scarcely touched upon the problem of ætiology, upon the question of the
ground in which the pathogenic process takes root. I now learned from my
rapidly increasing experience that it was not _any_ kind of emotional
excitation that was in action behind the phenomena of the neurosis but
regularly one of a sexual nature, whether it was a current sexual
conflict or the effect of earlier sexual experiences. I was not prepared
for this conclusion and my expectations played no part in it, for I had
begun my investigation of neurotics quite unsuspectingly. While I was
writing my “History of the Psycho-Analytic Movement” in 1914, there
recurred to my mind some remarks that had been made to me by Breuer,
Charcot and Chrobak, which might have led me to this discovery earlier.
But at the time I heard them I did not understand what these authorities
meant; indeed they had told me more than they knew themselves or were
prepared to defend. What I heard from them lay dormant and passive
within me, until the chance of my cathartic experiments brought it out
as an apparently original discovery. Nor was I then aware that in
deriving hysteria from sexuality, I was going back to the very
beginnings of medicine and following up a thought of Plato’s. It was not
until later that I learnt this from an essay by Havelock Ellis.
Under the influence of my surprising discovery, I now took a momentous
step. I went beyond the domain of hysteria and began to investigate the
sexual life of the so-called neurasthenics who used to visit me in
numbers during my consultation hours. This experiment cost me, it is
true, my popularity as a doctor, but it brought me convictions which
today, almost thirty years later, have lost none of their force. There
was a great deal of equivocation and mystery-making to be overcome, but
once that had been done, it turned out that in all of these patients
grave abuses of the sexual function were present. Considering how
extremely widespread are these abuses on the one hand and neurasthenia
on the other, a frequent coincidence between the two would not have
proved much; but there was more in it than that one bald fact. Closer
observation suggested to me that it was possible to pick out from the
confused jumble of clinical pictures covered by the name of neurasthenia
two fundamentally different types, which might appear in any degree of
mixture but which were nevertheless to be observed in their pure forms.
In the one type the central phenomenon was the anxiety attack with its
equivalents, rudimentary forms and chronic surrogate symptoms; I
consequently gave it the name of _anxiety neurosis_, and limited the
term _neurasthenia_ to the other type. Now it was easy to establish the
fact that each of these types have a different abnormality of sexual
life as its corresponding ætiological factor: in the former case _coitus
interruptus_, undischarged excitement and sexual abstinence, and in the
latter, excessive masturbation and too numerous nocturnal emissions. In
a few specially instructive cases, which had shown a surprising
alternation in the clinical picture from one type to the other, it was
possible to prove that there had been a corresponding change in the
underlying sexual _régime_. If it was possible to put an end to the
abuse and allow its place to be taken by normal sexual activity, a
striking improvement in the condition was the reward.
I was thus led into regarding the neuroses as being without exception
disturbances of the sexual function, the so-called “actual” neuroses
being the direct toxic expression of such disturbances and the
psycho-neuroses their mental expression. My conscience as a physician
felt pleased at my having arrived at this conclusion. I hoped that I had
filled up a gap in medical science, which, in dealing with a function of
such great biological importance, had failed to take into account any
injuries beyond those caused by infection or by gross anatomical
lesions. The standpoint of medicine was, moreover, favored by the view
that sexuality was not something purely mental. It had a somatic side as
well, and it was possible to assign special chemical processes to it and
to attribute sexual excitement to the presence of some particular,
though at present unknown, substance. There must also have been some
good reason why the true spontaneous neuroses resembled no group of
diseases more closely than the phenomena of intoxication and abstinence,
which are produced by the administration or privation of certain toxic
substances, or than Basedow’s disease, which is known to depend upon the
product of the thyroid gland.
Since that time I have had no opportunity of returning to the
investigation of the actual neuroses; nor has this part of my work been
continued by anyone else. If I look back today at my early findings,
they strike me as being the first rough outlines of what is probably a
far more complicated subject. But on the whole they seem to me still to
hold good. I should have been very glad if I had been able, later on, to
make a psychoanalytical examination of some more cases of simple
juvenile neurasthenia, but unluckily the occasion did not arise. To
avoid misconceptions, I should like to make it clear that I am far from
denying the existence of mental conflicts and of neurotic complexes in
neurasthenia. All that I am asserting is that the symptoms of these
patients are not mentally determined or removable by analysis, but that
they must be regarded as direct toxic consequences of disturbed sexual
chemical processes.
During the years that followed the publication of the _Studien_, having
reached these conclusions upon the part played by sexuality in the
ætiology of the neuroses, I read some papers on the subject before
various medical societies, but was only met with incredulity and
contradiction. Breuer did what he could for some time longer to throw
the great weight of his personal influence into the scales in my favor,
but he effected nothing and it was easy to see that he too shrank from
recognizing the sexual ætiology of the neuroses. He might have crushed
me or at least disconcerted me by pointing to his own first patient, in
whose case sexual factors had ostensibly played no part whatever. But he
never did so, and I could not understand why this was until I came to
interpret the case correctly and to reconstruct, from some remarks which
he had made, the conclusion of his treatment of it. After the work of
catharsis had seemed to be completed, the girl had suddenly developed a
condition of “transference love”; he had not connected this with her
illness, and had therefore retired in dismay. It was obviously painful
to him to be reminded of this apparent _contretemps_. His attitude
towards me oscillated for some time between appreciation and bitter
criticism; then accidental difficulties arose, as they never fail to do
in a strained situation, and we parted.
Another result of my taking up the study of nervous disorders in general
was that I altered the technique of catharsis. I abandoned hypnosis and
sought to replace it by some other method, because I was anxious not to
be restricted to treating hysteriform conditions. Increasing experience
had also given rise to two grave doubts in my mind as to the use of
hypnosis even as a means to catharsis. The first was that even the most
brilliant results were liable to be suddenly wiped away if my personal
relation with the patient became disturbed. It was true that they became
reestablished if a reconciliation could be effected; but such an
occurrence showed that the personal emotional relation between doctor
and patient was after all stronger than the whole cathartic process, and
it was precisely that factor which escaped every effort at control. And
one day I had an experience which showed me in the crudest light what I
had long suspected. One of my most acquiescent patients, with whom
hypnosis had enabled me to bring about the most marvellous results, and
whom I was engaged in relieving of her suffering by tracing back her
attacks of pain to their origins, as she woke up on one occasion, threw
her arms round my neck. The unexpected entrance of a servant relieved us
from a painful discussion, but from that time onwards there was a tacit
understanding between us that hypnotic treatment should be discontinued.
I was modest enough not to attribute the event to my own irresistible
personal attraction, and I felt that I had now grasped the nature of the
element of mystery that was at work behind hypnosis. In order to exclude
it, or at all events to isolate it, it was necessary to abandon
hypnosis.
But hypnosis had been of immense help in the cathartic treatment, by
widening the field of the patient’s consciousness and putting within his
reach knowledge which he did not possess in his waking life. It seemed
no easy task to find a substitute for it. While I was in this
perplexity, a recollection came to my help of an experiment which I had
often witnessed while I was with Bernheim. When the subject awoke from
the state of somnambulism, he seemed to have lost all memory of what had
happened while he was in that state. But Bernheim maintained that the
memory was present all the same; and if he insisted on the subject
remembering, if he asseverated that he knew it all and had only to say
it, and if at the same time he laid his hand on the subject’s forehead,
then the forgotten memories used in fact to return, hesitatingly at
first, but eventually in a flood and with complete clarity. I determined
that I would act in the same way. My patients, I reflected, must in fact
“know” all the things which had hitherto only been made accessible to
them by hypnosis; and assurances and encouragement on my part, assisted
perhaps by the touch of my hand, would, I thought, have the power of
forcing the forgotten facts and connections into consciousness. No doubt
this seemed a more laborious process than putting them under hypnosis,
but it might prove highly instructive. So I abandoned hypnosis, only
retaining my practice of requiring the patient to lie upon a sofa while
I sat behind him, seeing him, but not seen myself.